MICHEI   LOUTFALLAH 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

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fal    • 


OPHTHALMIC  SURGERY 
MELLER 


A    Handbook  of  the  Surgical  Operations  on  the  Eyeball 

and  Its  Appendages  as  Practiced  at  the  Clinic 

of   Prof.   Hofrat  Fuchs. 


BY 

DR.  JOSEF  MELLER 

Privatdocent  and  First  Assistant  K.  K.  77,  University  Eve  Clinic.  Vienna. 


THE  TRANSLATION  REVIEWFD  BY 

WALTER  L.  PYLE,  A.  M.,  M.  D. 

Member  of  the  American  Ophthalmologica!  Society.    Ophthalmologist  to  Mount  Sinai  Hospital. 
,        Sometime  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia,  etc. 


WITH   11K  ORIGINAL  ILLUSTRATIONS 


PHILADELPHIA 
P.    BLAKISTON'S  SON   &   CO 

1012   WALNUT   STREET 
1908 


The  Ktght  of  Translation  js  Reserved. 


COPYRIGHT,  1908,  BY  P.  BLAKISTON'S  SON  &  CO. 

Registered  at  Stationers'  Hall,  London,  England. 


Printed  by 

The  .\faple  Press, 

York,  Pa. 


PREFACE 


THE  forelying  volume  is  based  on  the  lectures  which  for  years  I 
have  given  during  the  courses  in  Ophthalmic  Surgery  at  the  Clinic 
of  Professor  Fuchs,  in  Vienna.  Among  the  numerous  visiting 
physicians  who  have  attended  these  lectures,  many  have  come  from 
English-speaking  countries,  and  it  is  in  pursuance  of  their  oft- 
expressed  wish  that  this  publication  has  been  made. 

In  consecutive  chapters  there  are  described  in  detail  and  pictured 
the  most  important  ophthalmic  operations,  as  they  are  performed 
at  the  Clinic  of  my  Chief,  Hofrat  Fuchs.  Under  his  valuable 
guidance,  my  clinical  education  and  cultivation  have  been  acquired, 
and  a  large  part  of  the  operative  procedures  herein  set  forth  I  have 
learned  from  him  personally.  Although  presented  under  the 
names  of  their  originators,  many  of  the  operations  are  described 
with  the  modifications  and  improvements  which  the  very  extensive 
experience  in  our  Clinic  has  gradually  led  us  to  adopt  as  the  best 
routine  practice.  Some  of  the  methods,  however,  are  essentially 
my  own:  for  example,  the  extirpation  of  the  tear-sac.  Had  I  not 
been  much  pressed  for  time,  these  would  have  been  published 
years  ago.  As  it  is,  I  now  for  the  first  time  publicly  present  them 
in  this  book. 

I  take  this  opportunity  of  acknowledging  my  indebtedness  to  Dr. 
M.  Sachs,  the  former  first  assistant  of  the  Clinic,  to  whose  staff  I 
was  attached  as  a  beginner  in  ophthalmology.  To  him  I  offer 
assurance  of  warmest  thanks  and  sincere  devotion.  The  drawings 
for  the  illustrations  are  from  the  skillful  hand  of  Wenzel,  who  gave 
himself  to  his  difficult  labor  with  great  earnestness  and  artistic 
care.  To  Dr.  William  M.  Sweet  my  thanks  are  due  for  his 
friendly  counsel  and  aid  in  effecting  the  publication  of  my  work. 
I  also  desire  to  record  my  appreciation  of  the  faithful  and  scholarly 
assistance  of  Dr.  Walter  L.  Pyle,  in  reviewing  the  English  transla- 
tion of  my  manuscript. 

JOSEF  MELLER. 

Vienna,   June,   1908. 

v 


CONTENTS 


CHAPTER  I. 

EXTIRPATION  OF  THE  LACHRYMAL  SAC i 

Topographical  anatomy  of  the  lachrymal-sac  region;  the  anterior  lach- 
rymal crest  and  the  internal  canthal  ligament;  the  most  important 
landmarks  for  the  finding  of  the  sac;  incision  through  skin  and  super- 
ficial fascia;  insertion  of  Mueller's  speculum;  division  of  the  muscle; 
clearing  of  the  deep  fascia;  incision  of  the  deep  fascia  along  side  of  the 
crest;  peeling  of  the  sac  from  its  capsule:  first  along  the  lateral  wall 
with  division  of  the  lachrymal  canaliculi,  then  along  the  median  wall, 
and  finally  dissection  of  the  apex  and  resection  of  the  sac  from  the  duct ; 
curettement  of  the  duct,  suture  and  pressure -dressing;  healing  by  first 
intention;  retention  of  secretion. 

CHAPTER  II. 

EXTIRPATION  OF  THE  LACHRYMAL  SAC.     (CONTINUED.) 15 

Anesthesia  and  anemia  of  the  field  of  operation;  importance  of  deep 
injections;  the  operation  is  bloodless  and  painless;  difficulty  of  oper- 
ation; direction  of  the  dissection  toward  the  bone;  injury  of  the  fascia; 
fultility  of  curettement  for  removal  of  retained  particles  of  the  sac;  for- 
mation of  fistula;  necessity  of  a  second  dissection  of  the  remnants  of 
the  sac;  dilatation  of  the  sac;  tuberculosis  of  the  sac;  treatment  of 
acute  dacryocystitis;  indications  for  extirpation  of  the  lachrymal  sac. 

CHAPTER  III. 

EXCISION  OF  THE  PALPEBRAL  LACHRYMAL  GLAND 22 

Indications;  section  of  the  excretory  ducts  of  the  orbital  gland;  preserva- 
tion of  the  tarso-orbital  fascia;  no  danger  of  a  drying  of  the  conjunc- 
tiva; probing;  course  of  the  lachrymal  canaliculi;  dilatation  with  the 
conical  probe;  production  of  a  false  passage;  slitting  the  canaliculus 
for  the  purpose  of  passing  probes  is  not  to  be  recommended;  indica- 
tions for  slitting;  treatment  of  beginning  ectropion;  slitting  with  the 
aid  of  Weber's  knife;  introduction  of  Bowman's  probe;  lavage  of  the 
sac  with  fluids  inducing  anesthesia  and  anemia;  Ariel's  syringe;  prob- 
ing through  the  upper  lachrymal  duct;  probing  in  newborn  children; 
indications  for  probing;  causes  of  epiphora;  hollow  probes. 

CHAPTER  IV. 

TRICHIASIS-OPERATIONS 32 

Typical  methods;  method  of  Anagnostakis  (Hotz);  modifications  of 
this  method;  shaving  of  the  tarsus;  rolling  forward  of  the  thinned  tar- 
sus by  the  sutures;  fixation  of  the  suture  at  the  upper  edge  of  the  tar- 

vii 


viii  CONTENTS. 

sus;  advantages  and  disadvantages  of  the  operation;  importance  of 
the  incision  in  the  intermarginal  border;  method  of  Panas;  division  of 
tarsus  and  conjunctiva  near  the  margin  of  the  lid;  fixation  of  the  suture 
in  the  tarsus  near  the  margin  of  the  wound;  advantage  of  the  opera- 
tion: radical  cure  of  the  trichiasis;  disadvantages:  shortening  of 
the  upper  lid;  danger  of  necrosis;  operation  of  Spencer  Watson 
for  partial  trichiasis;  atypical  operations;  transplantation  of  the  mu- 
cous membrane  of  the  lip;  the  outer  skin  must  not  be  employed  for  this, 
electrolytic  epilation. 

CHAPTER  V. 

ECTROPION -OPERATIONS 42 

Spastic  ectropion:  Snellen's  suture;  senile  ectropion:  combination 
of  the  methods  of  Kuhnt  and  Szymanowski;  shortening  of  the  tarsus  and 
skin  of  the  lid;  the  intermarginal  incision;  measurement  of  the  piece 
of  tarsus  to  be  excised;  shape  of  the  piece  of  skin  to  be  excised;  three 
sutures  through  the  tarsus;  displacement  of  the  skin  outward  with  simul- 
taneous slight  elevation;  necessity  of  a  dressing  over  both  eyes;  ad- 
vantages of  the  operation;  paralytic  ectropion:  tarsorrhaphy;  cica- 
tricial  ectropion;  plastic  operations;  use  of  sutures;  employment  of  flaps 
with  pedicles;  advantage  of  flaps  without  pedicles;  technic  of  trans- 
plantation of  flaps  without  pedicles;  production  of  a  wound-surface 
of  as  great  a  size  as  possible;  manner  of  preparation  from  the  skin  of 
the  arm;  the  most  perfect  adaptation  possible;  after-treatment. 

CHAPTER  VI. 

OPERATIONS  FOR  SPASTIC  ENTROPION 58 

Gaillard's  suture;  excision  of  an  obliquely  oval  piece  of  skin;  shortening 
of  the  skin  in  a  perpendicular  direction;  Graefe's  entropion -operation; 
shortening  of  the  skin  in  an  oblique  direction;  canthoplasty;  Ammon's 
operation;  provisional  canthoplasty;  indications;  Kuhnt's  canthoplasty: 
formation  of  a  skin -flap;  tarsorrhaphy;  indications;  method  of  Fuchs; 
advantage  of  the  growing  together  of  planes;  tarsorrhaphy  as  a  cosmetic 
operation;  total  closure  of  the  palpebral  fissure;  median  tarsorrhaphy; 
preservation  of  the  lachrymal  canaliculi  and  the  internal  canthus; 
method  of  Arlt. 

CHAPTER  VII. 

PlOSIS-OPERATIONS 71 

Method  of  Hess;  undermining  of  the  skin  of  the  lid;  production  of 
a  union  with  the  tfrontalis  muscle;  moist  chamber  for  two  to  three 
weeks;  good  result;  indications;  Pagenstecher's  suture;  operation  of 
Everbusch;  advancement  of  the  levator  palpebrae;  topographical  anat- 
omy of  the  field  of  operation;  preparation  of  the  muscle;  shortening 
of  the  muscle ;  indications ;  advantages  and  disadvantages  of  the  method ; 
Panas's  operation  for  ptosis  is  not  to  be  recommended  for  cosmetic 
reasons;  Motais'  method. 

CHAPTER  VIII. 

STRABISMUS-OPERATIONS 84 

The  technic  of  tenotomy;  grasping  of  the  tendon-insertion  with 
forceps;  the  technic  of  advancement;  application  of  loop-sutures; 
shortening  of  the  muscle;  suturing  of  the  muscle  to  the  sclera 
near  the  limbus;  technic  of  the  suture  through  the  sclera;  fixation 


CONTENTS.  IX 

of  the  muscle  to  the  conjunctiva  alone  is  insufficient;  application  of 
the  strabismus-operations;  how  much  correction  does  tenotomy  pro- 
duce; the  assisting  suture;  its  indications;  the  counteracting  suture; 
its  application;  how  much  does  advancement  correct?;  importance  of 
suturing  forward  to  the  limbus;  allowance  of  the  immediate  result 
of  advancement;  incalculable  action  of  tenotomy  and  advancement, 
when  performed  at  the  same  time;  the  advancement  is  the  physiologic- 
ally more  valuable  operation;  under-correction  in  convergent  stra- 
bismus; over-correction  in  divergent  strabismus;  operation  of  cases 
of  convergent  strabismus  of  slight  degree  (to  15  degrees);  medium 
degree  (to  30  degrees);  high  degree  (over  30  degrees);  difference  in 
the  value  of  tenotomy  and  advancement  of  the  internal  rectus  in  pro- 
portion to  the  same  operation  on  the  external  rectus;  simultaneous  per- 
formance of  advancement  of  the  internal  rectus  and  tenotomy  of  the 
external  rectus  in  divergent  strabismus;  assisting  suture  for  the  opera- 
tion of  divergent  strabismus;  advancement  of  the  internal  rectus  after 
tenotomy;  unpleasant  results  of  tenotomy;  operation  in  exophoria;  op- 
eration for  paralytic  strabismus;  value  of  strabismus-operations  almost 
only  cosmetic;  time  to  perform  the  operation. 

CHAPTER  IX. 

KMVI.EATIOX  OF  THE  EYEBALL  AND  ALLIED  OPERATIONS 103 

Technic  of  enucleation;  performance  of  the  operation  under  cocain- 
anesthesia;  necessity  of  preserving  the  conjunctiva;  resection  of  the 
optic  nerve;  hemorrhage;  indications  for  enucleation;  procedure  in 
panophthalmitis;  evisceration  of  the  bulb;  optico-ciliary  neurotomy; 
compensatory  operation  for  enucleation;  indications;  immediate  com- 
pression after  resection  of  the  optic  nerve;  exenteratio  orbits;  indica- 
tions and  technic  of  the  operation;  subperiosteal  preparation. 

CHAPTER  X. 

PLASTIC  OPERATIONS 115 

Plastic  lid -operations  having  a  pedicle;  method  of  Fricke;  to  prevent 
recurrence  of  epitheliomas  the  operation  must  be  performed  at  leas!  '. 
cm.  beyond  the  visible  margin  of  the  tumor;  disadvantage  of  Dieffen- 
bach's  method;  Buedinger's  ear-cartilage  method;  shaving  down  and 
thinning  of  the  ear-cartilage;  attachment  of  the  skin-ear-cartilage  flap 
to  the  lid-flaps;  protection  of  cornea  through  the  drawn-down  upper 
lid;  difficulties  in  replacing  an  entire  upper  lid;  operations  for  sym- 
blepharon;  sutures;  pediculated  flaps  from  the  surrounding  conjunctiva; 
non-pediculated  flaps  from  the  conjunctival  fornix;  futility  of  grafting  of 
rabbit  conjunctiva;  both  wound -surfaces  should  be  covered;  employ- 
ment of  skin-flaps  from  the  surrounding  tissue  with  pedicles;  method 
of  Rogman;  combination  of  it  with  a  plastic  operation  of  the  con- 
junctiva; employment  of  cutaneous  flaps  without  pedicles;  formation 
of  conjunctival  sacs  to  enable  the  wearing  of  protheses. 

CHAPTER  XI. 

OPERATION  FOR  SENILE  CATARACT 124 

Technic  of  the  individual  steps;  fixation  of  the  eye;  use  of  the 
right  and  left  hand;  avoidance  of  the  slightest  pressure  on  the  eyeball 
"with  the  forceps;  grasping  of  the  conjunctival  fold  in  the  vertical 
meridian;  technique  of  position;  position  of  the  incision;  discussion 


X  CONTENTS. 

of  the  relative  position  of  the  limbus  and  the  angle  of  the  chamber; 
after  perforation  of  the  anterior  chamber  the  knife  must  neither  be  pulled 
back  nor  checked  in  its  advance;  turning  of  the  knife  beneath  the 
conjunctiva;  iridectomy;  use  of  Wecker's  scissors;  opening  of  the  anterior 
lens-capsule;  the  capsule-forceps  and  its  use;  a  large  piece  of  the  anterior 
capsule  must  be  pulled  out;  use  of  the  cystotome;  advantage  of 
the  capsule-forceps;  expression  of  the  cataract;  delivery  of  the  cortical 
substance;  toilet  of  the  eye;  reposition  of  the  iris;  management  of 
the  spatula;  proper  position  of  the  conjunctival  flap. 

CHAPTER  XII. 

OPERATION  FOR  SENILE  CATARACT.     (CONTINUED.) 140 

Discussion  of  complications  and  mistakes;  other  remarks;  tearing  out 
of  conjunctiva;  fixation  of  the  eye  to  a  muscle -attachment;  corneal  in- 
cision; scleral  incision;  disadvantage  of  both;  length  of  the  incision; 
too  short  an  incision;  direction  of  the  incision;  intralamellar  incision; 
method  of  holding  the  knife;  use  of  the  right  and  left  hand;  hemorrhage 
in  iridectomy;  the  eye  should  be  fixed  only  during  the  incision;  produc- 
tion of  iridodyalisis;  the  iris  falls  against  the  knife;  bridge-colo- 
boma;  indication  for  the  use  of  the  cystotome;  procedure  when  the 
anterior  lens-capsule  is  markedly  tense  or  is  thickened;  extraction  of 
the  lens  in  the  capsule;  causes  which  prevent  the  delivery  of  the 
lens:  too  short  an  incision;  resistance  of  the  sphincter;  the  anterior 
capsule  is  not  opened;  dislocation  of  the  lens;  diminution  in  size  of 
the  lens-nucleus;  prolapse  of  vitreous;  Weber's  loop;  Reisiger's  hook; 
symptoms  of  the  approaching  or  beginning  vitreous  prolapse;  pouring 
out  of  fluid  vitreous;  luxation  of  the  lens  into  the  vitreous;  corneal 
collapse;  expulsive  hemorrhage;  extraction  without  iridectomy;  ad- 
vantages and  disadvantages;  indications;  excision  of  the  prolapse. 

CHAPTER  XIII. 

OPERATIONS  ON  THE  SOFT,  TRANSPARENT  OR  CATARACTOUS  LENS 159 

Discission  per  corneam;  crucial  incision  into  the  anterior  lens-capsule; 
attention  to  prevent  injuring  the  posterior  capsule;  discission  of  the 
transparent  lens  in  myopia  operations;  production  of  traumatic  cata- 
ract; puncture  to  remove  the  swollen  lens-masses;  procedure  to  pre- 
vent increase  in  tension;  indications  for  myopia -ope  rations;  their  value; 
discission  of  partial  cataracts;  procedure  in  perinuclear  cataract; 
viscual  acuity  by  narrow  and  wide  pupil;  discission  or  optical  iridec- 
tomy; technique  of  the  latter;  pre-corneal  iridotomy;  other  indications 
for  optical  iridectomy;  estimation  of  the  probable  value  of  an  optical 
iridectomy  in  corneal  opacities;  movable  stenopaeic  slit  or  fissure; 
dilatation  of  the  pupil  for  purposes  of  examination;  provisional  tattooing 
of  the  cornea;  successes  of  optical  iridectomy;  discission  of  completely 
dimmed  lenses;  operation  for  complete  congenital  cataract;  advantage 
of  discission  as  compared  with  linear  extraction  in  small  children. 

CHAPTER  XIV. 

OPERATIONS  FOR  SOFT  CATARACT  AND  SECONDARY  CATARACTS 169 

Discission  per  corneam  in  operation  for  secondary  cataract;  injury  of 
the  vitreous;  necessity  of  dilatation  of  the  pupil  by  atropin;  laceration 
in  the  iris-attachment;  transient  depression  of  the  membrane  into 
the  vitreous;  Bowman's  discission;  capsulotomy  and  iridotomy  in  com- 


CONTENTS.  XI 

plicated  secondary  cataract;  scar-formation  after  extraction  during 
iridocylitis;  use  of  Graefe's  knife  for  the  incision;  importance  of  an 
immediate  pressure -dressing  to  prevent  hemorrhage;  direction  of  the 
incision;  advantages  of  this  method  of  operation;  discission  per  scleram; 
technique  of  the  operation;  advantage  as  compared  with  discission 
per  corneam;  unpleasant  complications:  glaucoma;  cyclitis;  linear 
extraction;  upper  limit  of  age  thirty-five  years;  technic  of  the  operation; 
extraction  of  the  soft  lens-masses  by  massage;  enlargement  of  the  in- 
cision laterally  in  the  presence  of  a  large  nucleus;  careful  treatment  of 
the  iris;  extraction  of  the  lens  with  the  capsule;  prolapse  of  vitreous; 
suture. 

CHAPTER  XV. 

OPERATIONS  FOR  GLAUCOMA 180 

Iridectomy  in  glaucoma;  technic  of  the  individual  steps;  incision; 
relative  position  of  angle  of  chamber  and  limbus;  the  incision  with  the 
lancet;  beginning  of  incision  i£  mm.  behind  the  limbus;  fixation 
of  the  eye  in  the  vertical  meridian;  change  of  position  of  the  lancet 
into  the  plane  of  the  iris;  direction  and  length  of  incision;  difficulty  of 
the  lancet-incision;  the  lancet  must  be  pulled  out  slowly;  the  incision 
with  Graefe's  knife;  indications;  advantages  of  the  incision  with  the 
lancet;  the  incision  with  the  knife  is  less  dangerous;  difference  between 
this  iris-operation  and  the  iridectomy  in  cataract-operations;  difficulty 
of  reposition;  indications  for  iridectomy;  complications  during  the 
operation;  tearing  out  of  the  conjunctiva;  intralamellar  incision;  im- 
paling of  the  iris;  production  of  iridodyalisis  during  the  incision  with 
the  lancet;  injury  of  the  lens;  incorrect  position  of  the  incision;  anes- 
thesia of  the  iris  before  operation;  caution  during  the  use  of  the  iris- 
forceps  because  of  possible  injury  of  the  lens-capsule;  iridectomy  at 
the  lower  part  of  the  iris;  hemorrhage  during  the  operation;  im- 
portance of  reposition ;  liberation  of  a  part  of  the  iris  held  into  the  wound ; 
prolapse  of  the  vitreous;  expulsive  hemorrhage. 

CHAPTER  XVI. 

OPERATIONS  FOR  GLAUCOMA.  (CONTINUED.) 193 

Complications  of  iridectomy  for  glaucoma;  subluxation  of  the  lens;. for- 
mation of  a  cataract;  injury  of  the  lens-capsule  produced  by  the  oper- 
ator; spontaneous  rupture  of  the  lens-capsule;  rupture  of  the  capsule 
at  the  lens-equator;  spontaneous  emersion  of  the  lens  from  the  eye; 
technic  of  cyclodyalisis  after  Heine;  liberation  of  the  ciliary  body  from 
the  sclera;  avoiding  injury  of  the  anterior  ciliary  veins  and  the  ciliary 
body;  no  danger  of  iridodyalisis  after  an  injury  to  the  canal  of  Schlemm; 
pressure-dressing  if  hemorrhage  is  started;  the  operation  certainly 
does  not  act  only  because  of  the  puncture;  diminution  of  tension  with- 
in a  few  days;  value  of  cyclodyalisis;  operations  for  secondary  glau- 
coma; puncture  of  the  cornea;  technique  of  the  operation;  prevention 
of  the  loss  of  aqueous  humor  during  the  incision;  repetition  of  the  punc- 
ture; prolongation  of  the  incision  to  remove  masses  of  lens-matter;  diffi- 
culty of  performing  iridectomy  in  secondary  glaucoma;  procedure  in 
subluxation  and  luxation  of  the  lens;  transfixion;  anterior  sclerotomy; 
incision  of  the  angle  of  the  chamber;  iridodyalisis;  results  of  the  oper- 
ation; indications;  posterior  sclerotomy;  incision  at  the  meridian;  no 
filtration -scar;  results  and  indications. 


\ii  CONTENTS. 

CHAPTER  XVII. 

OPERATIONS  FOR  PROLAPSE  OF  THE  IRIS  AND  ITS  SEQUELA:  ANTERIOR 
SYNECHIA;  ECTASIA  OF  THE  SCAR,  ETC.,  CORNEAL  AND  CONJUNCTIVAL 

PLASTIC  OPERATIONS 209 

Every  prolapse  must  be  excised;  technic  of  excision;  removal  of  the 
fibrous  layer;  liberation  of  the  prolapse  with  the  conical  probe;  draw- 
ing the  iris  forward;  amputation  at  the  edge  of  wound;  reposition  of 
the  portion  of  the  iris;  resection  in  perforation  of  ulcers;  difficulties  of 
the  operation;  healing  of  the  perforation  opening;  if  prolapse  is  too 
large,  it  must  not  be  excised;  iridectomy  when  considerable  of  the 
iris  is  healed  in  the  wound;  serpigineous  ulcer  in  the  stage  of  scarifica- 
tion and  in  glaucoma;  plastic  operations  on  conjunctiva;  development 
of  the  operation  through  Kuhnt;  flaps  with  a  pedicle  cover  the  defect; 
de  Wecker's  procedure  to  cover  corneal  defects;  prolapse  of  the  ciliary 
body  or  chorioid;  application  of  the  scleral  suture;  procedure  by 
prolapse  existing  for  some  time;  iridectomy  and  pressure  dressing  to 
flatten  the  recent  scar;  cutting  off  of  the  scar  and  excision  of  the  iris. 

CHAPTER  XVIII. 

CORNEAL  OPERATIONS 216 

Fuchs'  corneal  transplantation  to  replace  ectatic  and  fistulous  scar- 
tissue  in  the  cornea;  technic  of  the  operation;  keratoplasty;  v.  Hippel's 
partial  keratoplasty;  total  keratoplasty;  worthlessness  of  the  operation 
from  the  optic  standpoint;  Hippel's  trephine;  indications  for  the  ker- 
atoplastic  restoration  of  corneal  scars;  general  indications  for  operative 
procedures,  particularly  in  anterior  synechia;  Sach's  temporary  scar- 
resection;  technique  of  the  operation;  injury  of  the  lens-capsule  when 
it  heals  in  the  corneal  scar;  liberation  of  a  portion  of  the  iris  healed  in 
the  scar;  procedure  for  cystic  scars  after  iridectomy  for  glaucoma., 

CHAPTER  XIX. 

EXTRACTION  OF  FOREIGN  BODIES  FROM  THE  INTERIOR  OF  THE  EYEBALL.  222 
Difficulty  of  the  operation;  diagnosis  of  intra -ocular  foreign  bodies; 
importance  of  examination  of  the  posterior  portion  of  the  eyeball  with 
the  ophthalmoscope;  sideroscopic  examination;  Roentgen  examination; 
deference  to  small  wounds  or  scars;  technic  of  extraction  with  the 
giant  magnet;  advancement  of  the  foreign  body  from  the  vitreous  to 
the  anterior  chamber;  extraction  of  a  foreign  body  from  the  anterior 
chamber;  use  of  Hirschberg's  magnet;  extraction  of  an  iron  splinter 
through  the  sclera;  indications;  prognosis  of  injuries  from  iron-splinters; 
extraction  of  particles  other  than  those  of  iron;  opening  of  the  eye- 
ball through  a  long  scleral  incision;  marked  facilitation  of  the  operation 
through  the  lamp  of  Sachs;  procedure  in  old  injuries. 

CHAPTER  XX. 

VARIOUS  MINOR  OPERATIONS.    REMARKS  CONCERNING  ANESTHESIA  AND 

ASSISTANCE 230 

Operative  treatment  of  serpigineous  ulcer;  subconjunctival  injections; 
cauterization  of  an  ulcer;  puncture  of  the  anterior  chamber;  Saemisch's 
operation;  frequent  repetition  of  the  incision;  iridectomy  to  prevent 
glaucoma;  operations  for  pterygium;  transplantation;  Arlt's  method; 
tattooing  of  the  cornea;  indications;  prickling  with  a  multiple  needle; 


CONTENTS.  Xlll 

use  of  the  hollow  needle;  Froehlich's  method  of  tattooing;  operations 
for  corneal  staphyloma;  method  of  Beer;  method  of  de  Wecker; 
possibility  of  sympathetic  ophthalmia;  squeezing  trachoma-granules 
from  the  conjunctiva;  roller-forceps  of  Knapp;  expression  by  Kuhnt's 
method;  concerning  assistance;  the  lid-speculum  is  an  instrument 
which  endangers  the  eyes;  Mueller's  lid-speculum;  help  rendered  by 
the  assistant  during  the  cataract -operation;  Desmarres'  spoon;  down- 
ward guiding  of  the  upper  lid  with  the  assistance  of  inserted  instru- 
ments; operation  without  fixation-forceps;  sponging;  other  aid  which 
the  assistant  may  render;  anesthesia;  advantage  of  local  anesthesia;  dis- 
advantage of  general  anesthesia;  use  of  adrenalin;  preference  given 
cocain  over  its  various  substitutes;  dropping  cocain  on  the  bared  iris; 
scopolamin-morphin-narcosis;  its  advantages;  Fuchs'  wire-shield; 
Snellen's  cup-shield. 

IXDEX 245 


OPHTHALMIC   SURGERY. 


CHAPTER  I. 
THE    LACHRYMAL    APPARATUS. 

EXCISION  OF  THE  LACHRYMAL  SAC. 

Anatomy. — Before  beginning  the  operation  it  is  necessary  to  under- 
stand the  relative  position  of  the  internal  palpebral  ligament  and 
the  anterior  lachrymal  crest.  By  placing  the  finger  against  the  outer 
canthus  and  stretching  both  lids  slightly  outward  in  a  horizontal  direc- 
tion, the  ligament  is  seen  at  the  inner  part  of  the  eye  as  a  slightly 
circumscribed  prominent  cord  immediately  beneath  the  skin.  This 
ligament  is  Y-shaped,  has  a  horizontal  part,  which  takes  its  origin  from 
the  bone,  whereas  the  two  branches  of  the  Y  are  continuous  with  the 
tarsal  parts  of  the  eyelids,  in  this  way  fastening  them  to  the  bone.  The 
lachrymal  sac  lies  behind  this  so-called  tendo  oculi  in  such  a  manner 
that  the  top  of  the  sac  is  on  the  level  of  the  horizontal  portion  of  the 
tendon,  the  sac  itself  extending  downward  from  it  for  its  entire  length. 

The  anterior  lachrymal  crest  is  the  most  important  landmark 
throughout  the  operation.  In  thin  individuals  it  may  at  times  be 
seen  through  the  skin;  in  all  other  cases  it  may  be  found  easily  by  per- 
mitting the  finger  to  glide  along  the  lower  orbital  edge  in  a  direction  up- 
ward and  inward.  In  some  instances  it  is  prominent,  forming  a  sharp 
border;  in  others,  it  is  flat  and  may  then  be  felt  much  better  by  sliding 
the  closed  forceps  from  the  side  of  the  nose  to  the  inner  wall  of  the  orbit. 
At  times  it  is  relatively  superficial;  at  others,  much  deeper.  At  a 
point  where  the  crest  forms  a  part  of  the  lower  bony  orbital  margin,  it 
is  always  very  prominent;  its  upper  half,  however,  is  usually  quite  flat. 
All  these  circumstances  are  of  considerable  importance  in  the  perform- 
ance of  the  operation.  The  more  superficial  the  crest,  the  more 
readily  it  is  reached,  and  the  easier  is  the  extirpation  of  the  sac;  the 
deeper  the  crest,  the  more  difficult  the  operation. 

The  method  recommended  for  the  extirpation  of  the  sac  has  proved 


2  OPHTHALMIC    SURGERY. 

eminently  satisfactory.  It  requires  an  accurate  knowledge  of  the  topo- 
graphic anatomy  of  this  region,  and  this  will  be  discussed  as  the  various 
stages  of  the  operation  are  described. 

In  the  dissection  of  the  structures  we  commence  the  incision 
through  the  skin,  beginning  at  a  point  2  mm.  above  the  ligament  of 
the  internal  canthus  and  3  mm.  to  the  inner  side  of  the  canthus.  The 
direction  of  this  incision  is  downward  and  in  its  lower  half  curved 
slightly  outward,  whereas  the  upper  half  has  to  be  perpendicular 
(Fig.  i).  If,  for  instance,  the  upper  half  of  the  cut  is  not  straight,  but 


FIG.  i. — With  the  thumb  of  the  left  hand  (1.  th.)  the  skin  is  fixed,  but  not  pulled  or 
stretched.  The  cutting  edge  of  the  knife  is  directed  vertically  against  the  bone.  The 
incision  is  downward,  slightly  outward  and  somewhat  curved;  3  to  4  mm.  distant  from 
internal  canthus. 

curved  towards  the  upper  lid,  an  ugly  fold  of  skin  is  frequently  produced 
at  the  upper  angle  of  the  incision  during  the  healing  process.  While 
making  the  incision,  which,  by  the  way,  corresponds  to  the  position 
of  the  crest,  we  must  not  pull  the  lids  outward  with  the  idea  of  making 
the  skin  tense.  This  would  prevent  the  incision  from  being  made  at 
the  desired  point.  It  is  sufficient  to  press  the  upper  inner  part  of  the 
skin  backward  against  the  bone  with  the  thumb.  If  we  use  a  sharp 
knife,  slight  pressure  against  the  skin  will  indicate  the  direction  of  the 
incision,  and  then  to  deepen  it  more  readily,  the  skin  may  still  be 
stretched. 

The  length  of  the  incision  is  not  of  much  importance.     The  be- 


THE    LACHRYMAL    APPARATUS.  3 

ginner  should  make  a  long  incision  (about  if  cm.),  as  this  facilitates 
the  dissection  of  the  sac.  The  expert  operator  usually  prefers  a  short 
incision.  The  length  of  the  cut  varies,  therefore,  from  i  cm.  to  if  cm. 
The  further  from  the  external  canthus  the  incision  is  made,  the  more 
difficult  becomes  the  dissection  of  the  sac  on  account  of  the  increasing 
distance  from  it. 

After  completing  the  cut,  the  edges  of  the  incision  are  lifted  up  and 
dissected  from  the  underlying  tissue  with  the  scalpel  turned  toward 
the  canthus,  so  the  wound  may  be  readily  opened  and  the  tearsac 
speculum  (Miiller's)  introduced  without  difficulty.  This  instrument 
is  of  great  advantage,  as  it  takes  the  place  of  an  assistant  and,  by  com- 
pressing the  surrounding  tissues,  aids  materially  in  hemostasis.  The 
speculum  is  introduced  closed,  and  to  insert  the  hooks  properly,  the 
wound  edges  must  first  be  lifted  gently  with  forceps.  Its  handle  is 
turned  downward  and  slightly  outward.  The  patient  must  keep  his 
eyelids  closed  throughout  the  entire  operation.  It  is,  of  course,  neces- 
sary during  the  introduction  of  the  instrument  to  fasten  the  hooks  se- 
curely into  the  wound  edges,  so  that  no  injury  of  the  cornea  be  produced 
by  any  sudden  jerking  loose;  since  even  an  erosion  might  become  dan- 
gerous because  of  the  great  liability  of  infection. 

In  the  wound,  pulled  open  with  the  aid  of  the  speculum,  is  laid  bare 
a  delicate,  thin,  white  membrane,  the  superficial  fascia.  Frequently 
this  is  considerably  thickened  in  the  direction  of  the  palpebral  fissure 
throwgh  layers  of  connective-tissue  fibers,  some  of  which  are  connected 
with  the  ligamentum  canthi,  and  radiate  from  it.  They  must  not  be 
confounded  with  the  true  ligament  of  the  canthus,  which  belongs  to  a 
deeper  stratum. 

In  place  of  the  scalpel,  with  which  the  main  incision  was  made,  we 
now  employ  a  small,  slightly  curved  pair  of  scissors,  both  blades  of 
which  are  pointed  and  with  these  the  operation  is  completed.  With 
tooth  forceps  we  pick  up  a  fold  of  the  superficial  fascia,  transfix  it 
with  one  blade  of  the  scissors  and  slit  it  throughout  the  entire  length  of 
the  wound,  pushing  it  back  toward  both  margins  of  the  same.  We 
thus  expose  a  layer  of  red  fibers,  the  orbicularis  muscle  (palpebral 
portion),  the  fibers  of  which,  as  is  known,  arise  from  the  internal  pal- 
pebral ligament. 

The  muscle  is  slit  up  in  the  same  manner  as  the  superficial  fascia 
and  the  fibres  pushed  back  toward  both  sides  with  the  closed  scissors. 
We  now  expose  to  view  in  the  floor  of  the  operative  wound  a  dense 


4  OPHTHALMIC    SURGERY. 

white  membrane,  the  deep  fascia,  which  covers  the  lachrymal  sac 
(Fig.  2).  This  extends  from  the  anterior  to  the  posterior  lachrymal 
crest  and  bridges  over  the  fossa  containing  the  lachrymal  sac.  Above, 
below  and  at  the  inner  side,  the  fascia  becomes  continuous  with  the 
periosteum  of  the  neighboring  bones;  but  at  the  posterior  lachrymal 
crest  it  fuses  with  the  orbital  septum,  thus  completing  the  membrane 


FIG.  2. — The  separation  and  pulling  to  either  side  of  the  muscle-fibers  (m)  exposes  the 
deep  fascia  (f.  p.)  in  the  wound;  behind  this  the  sac  must  be  looked  for.  In  the  upper 
angle  of  the  wound  are  the  transverse  fibers  of  the  ligament  of  the  internal  canthus  (1.  c.). 
Through  them  the  anterior  lachrymal  crest  (cr.  a.)  can  always  be  felt  and  can  usually  be 
seen. 


which  separates  the  lachrymal  fossa  from  the  orbit.     The  specially  thick- 
ened median  portions  of  this  fascia  form  a  prominent  dense  cord  which 

has  already  been  referred  to  as  internal  canthal  ligament. 

i 

The  fibers  visible  at  this  point  may  also  be  referred  to  as  the  anterior  branch  of 
the  ligament.  From  it  radiate  bundles  of  fibers  into  the  tarsus  of  the  upper  and 
lower  lid.  In  contradistinction  to  this  the  portion  of  the  fascia  attached  to  the 
posterior  lachrymal  crest  is  spoken  of  as  posterior  branch  of  the  ligament.  This 
arrangement,  useful  also  because  of  the  differences  in  insertion  of  the  muscle-fibers, 


THE    LACHRYMAL    APPARATUS.  5 

is  understood  without  difficulty,  when  a  horizontal  section  of  the  skull  made 
through  the  region  of  the  canthal  ligament  is  viewed.  By  pulling  the  lids  outward 
an  angular  folding  of  the  deep  fascia  is  produced,  which  bounds  a  triangular  space 
with  the  lachrymal  fossa.  Its  floor  is  formed  by  the  fossa  itself,  its  branches 
(anterior  and  posterior)  by  the  corresponding  portions  of  the  internal  canthal  liga- 
ments. In  this  triangle  is  to  be  found  the  cross-section  of  the  lachrymal  sac. 

At  this  stage  of  the  dissection  the  operator  sees  neither  the  crest, 
unless  it  is  abnormally  prominent,  nor  the  lachrymal  groove.  To  note 
their  exact  positions,  he  must  feel  around  with  the  forceps,  gliding  from 
the  side  of  the  nose  toward  the  orbit.  The  anterior  lachrymal  crest 
must  serve  as  landmark  during  the  entire  operation.  By  not  dissecting 
too  near  the  median  line  he  will,  on  the  one  hand,  escape  the  mistake 
of  incising  the  periosteum  of  the  dorsum  of  the  nose,  instead  of  freeing 
the  lachrymal  sac;  on  the  other  hand  keep  from  going  in  the  wrong 
direction  from  the  sac  toward  the  orbit. 

The  deep  jascia  has  to  be  split  now  with  the  scissors,  inserting  (he 
scissors  to  the  outer  side  of  the  anterior  lachrymal  crest,  1-2  mm. 
behind  it.  This  is  not  easy,  particularly  on  the  cadaver,  if  we  wish  to 
escape  injuring  the  sac.  One  difficulty  is  that  no  fold  of  tissue  can  be 
picked  up  for  transfixion  by  the  scissors,  as  the  fascia  is  very  tense. 
We  are,  therefore,  forced  to  perforate  the  layer  with  one  of  the  points 
of  the  scissors,  holding  the  instrument  almost  parallel  to  the  plane  of 
the  fascia.  It  is  our  custom  to  make  the  cut  through  the  fascia  1-2  mm. 
behind  the  crest,  and  not,  as  done  by  others,  right  on  the  crest, 
so  as  to  make  the  following  dissection  of  the  lateral  wall  easier. 

As  the  sac  lies  near  the  fascia,  its  anterior  wall  may  be  injured  by 
cutting  too  brusquely.  This  is  particularly  true  on  the  cadaver,  when 
the  sac  is  not  diseased  and  the  walls  are  therefore  thin  and  made 
friable  through  beginning  decomposition.  For  purposes  of  demon- 
stration (it  may  also  be  done  with  the  best  of  success  at  operations), 
it  is  as  well  to  slit  the  fascia  along  its  entire  length  with  a  narrow,  pointed 
knife  (Graefe's  linear  knife),  holding  it  obliquely  with  the  cutting  sur- 
face forward.  I  myself  prefer  to  use  the  scissors  for  this  cut.  The 
danger  of  injuring  the  tearsac  can  be  diminished  by  drawing  away  the 
fascia  from  it,  by  taking  the  ligament  with  the  forceps  and  pulling  it 
outward  and  forward.  Moreover,  the  sac  being  thickened  in  the 
patient,  the  danger  of  injuring  it  is  reduced  to  a  minimum.  However, 
the  operator  should  begin  with  a  very  short  cut  through  the  fascia  so 
that  even  in  case  the  sac  is  injured,  its  perforation  need  not  be  extensive. 


6  OPHTHALMIC    SURGERY. 

This  cut  must  be  completed  through  the  whole  length  of  the  membrane, 
and  severs  the  ligament  of  the  canthus  at  the  same  time.  In  the  slit- 
like  opening  thus  produced  may  be  seen  the  lachrymal  sac,  readily 
distinguished  because  of  its  bluish  color  (Fig.  3).  In  operating 
on  living  patients,  it  is  not  uncommon  to  have  the  anterior  wall  of  the 
sac  bulge  through  the  opened  fascia  in  the  form  of  a  hernia. 

The  remainder  of  the  operation  consists  in  peeling  the  sac  out  of 


FIG.  3. — The  deep  fascia  is  incised  throughout  the  entire  length  of  the  wound  i  mm. 
behind  (i.e.,  to  the  side  of)  the  crest  (cr.  a.).  This  lays  bare  the  bluish-red  lachrymal  sac 
(sa.).  The  ligament  of  the  internal  canthus,  which  the  figure  shows  to  have  been  pre- 
served, is  cut  through  at  the  same  time. 

its  coverings.  From  now  on,  the  operator  must  constantly  keep  close 
to  the  wall  of  the  sac,  but  must  not  injure  the  fascia  or  cut  it  away 
at  the  same  time.  There  are  no  blood  vessels  of  note  in  the  loose  tissue 
connecting  the  sac  with  its  fascial  capsule,  and,  therefore,  during  the 
dissecting  there  will  be  no  annoying  hemorrhage. 

It  is  my  usual  custom  first  to  separate  the  lateral  wall  of  the  sac  from 
the  fascia.  For  this  purpose  I  pick  up  the  lateral  margin  of  the  fascial 
wound  with  tooth-forceps  and  separate  the  delicate  connective-tissue 


THE  LACHRYMAL  APPARATUS. 


7 


fibers  which  connect  the  sac  with  the  lateral  wall  of  the  fascia,  beginning 
in  the  lower  half  of  the  wound  and  using  for  the  purpose  the  edge  of  the 
closed  scissors  (Fig.  4).  With  a  few  strokes  the  lateral  wall  is  sepa- 
rated back  to  the  bone. 

It  is  only  when  reaching  the  upper  part  that  a  disturbing  factor  is  met. 
There  is  seen  a  bluish  cord  going  to  the  lid,  the  lachrymal  ducts. 


FK;.  4. — The  lateral  margin  of  the  fascial  wound  (f.  1.)  is  grasped  with  the  forceps,  and 
the  closed  scissors  made  to  separate  the  loose  areolar  tissue  between  sac  (sa.)  and  fascia , 
as  far  back  as  the  bone. 


These  must  be  directly  cut  as  close  to  the  fascia  as  possible — and  not 
dissected  by  the  closed  scissors — or  else  a  piece  of  the  mucous  membrane 
will  be  left  hanging  to  the  fascia.  Next,  the  median  wall  of  the  sac 
is  loosened.  Should  the  portion  of  the  fascia  left  behind  at  the  crest 
be  too  broad  to  free  the  crest  easily,  an  incision  must  be  made  into  it 
(j  in  Fig.  6).  Gliding  along  the  upper  flat  half  of  the  crest  with  the 


8  OPHTHALMIC    SURGERY. 

point  of  the  closed  scissors,  it  is  an  easy  matter  to  separate  the  wall  of 
the  sac  from  the  bone  (Fig.  5).  On  the  cadaver  it  is  often  possible  to 
preserve  the  periosteum  of  the  lachrymal  bone,  but  on  the  living 
subject  adhesions  nearly  always  compel  the  removal  of  the  periosteum 
with  the  wall  of  the  sac.  Because  of  this,  the  bone  is  denuded  over  the 
lachrymal  fossa,  but  no  importance  need  be  accorded  the  injury.  We 


FIG.  5. — A  short  transverse  cut  (easily  seen  in  Fig.  6  (i),  while  in  this  drawing  it  is 
pulled  to  one  side  by  the  forceps)  into  the  median  margin  of  the  fascial  wound  exposes  the 
anterior  crest  (cr.  a.);  this  makes  it  easy  to  push  the  closed  scissors  between  the  bone  and 
sac  (sa.)  at  the  upper  part  of  the  crest  and  to  loosen  the  sac.  The  point  of  the  scissors 
is  directed  toward  the  bone. 

continue  to  proceed  with  the  point  of  the  closed  scissors  to  the  posterior 
lachrymal  crest.  If  the  upper  half  of  the  median  portion  of  the  sac 
had  been  freed,  it  will  not  be  difficult  to  peel  its  lower  half  from  behind 
the  prominently  projecting  crest  without  injuring  the  sac;  but  if  the 
preparation  for  excision  has  been  begun  at  the  lower  steep  portion  of 
the  crest,  the  sac  will  usually  be  injured.  This  is  a  mistake  frequently 
committed  by  beginners. 


THE    LACHRYMAL    APPARATUS.  9 

The  sac  has  now  been  cleared  from  all  sides,  but  at  the  upper  pole 
its  apex  is  still  fastened  to  the  surrounding  structures,  while  at  the  lower 
point  it  is  continuous  with  the  mucous  membrane  of  the  duct.  For 
the  first  time  since  the  operation  began  we  can  now  grasp  the  entire 
sac  with  the  forceps  without  fearing  the  risk  of  tearing  it,  and  dissect 


FIG.  6. — The  sac,  having  been  freed  on  both  sides,  is  now  for  the  first  time  grasped  with 
forceps  near  its  apex  (t)  and  separated  from  the  surrounding  structures  with  sharp  cuts  of 
the  scissors  as  near  the  sac  wall  as  possible.  The  upper  margin  of  the  wound  is  lifted  up 
with  a  double  tenaculum.  (See  Fig.  5  (i),  transverse  cut  into  fascia.) 

it  out  of  the  surrounding  fascia  with  which  its  top  is  intimately  united, 
making  small  nicks  with  the  scissors  as  near  as  possible  to  the  wall  of 
the  sac  (Fig.  6). 

This  freeing  of  the  top  is  a  difficult  part  of  the  operation.  It  may 
readily  happen  if  all  the  sac  is  not  removed,  that  troublesome  dis- 
charge continues.  We  must  also  be  careful  not  to  cut  too  much  tissue 


10 


OPHTHALMIC    SURGERY. 


away  with  the  apex,  as  in  such  case  injury  to  larger  blood-vessels  is  a 
common  occurrence.  This,  by  setting  up  considerable  bleeding,  will 
hide  from  view  the  field  of  operation  lying  beneath.  In  spite  of  the 
greatest  caution,  we  sometimes  have  profuse  hemorrhage.  Because 
of  this,  I  have  recommended  not  to  dissect  the  top  until  the  entire  sac 
has  been  completely  shelled  out.  Even  should  a  considerable  bleeding 


FIG.  7. — The  sac,  having  been  freed  from  the  surrounding  structures  at  all  points  except 
at  its  lowest  portion,  is  grasped  with  the  forceps  low  down ;  the  vertically  held  scissors  are 
made  to  cut  away  all  the  tissue  attached  to  its  anterior  wall  as  close  to  it  as  possible  until 
the  naso-lachrymal  duct  is  reached. 

then  occur,  it  need  not  cause  much  annoyance,  as  the  entire  sac  is  safely 
held  in  the  forceps. 

As  soon  as  the  upper  portion  has  been  freed,  the  entire  sac  may  be 
pulled  forward.  Should  its  posterior  surface  still  be  attached  to  the 
bone  by  a  few  connective-tissue  fibers,  a  few  strokes  with  the  closed 
scissors  will  suffice  to  separate  them. 

The  next  step  is  to  dissect  the  sac  downward  as  far  as  possible. 


THE    LACHRYMAL    APPARATUS.  II 

For  this  purpose  I  take  hold  of  the  sac  with  the  forceps  at  as  low  a 
point  as  possible  (Fig.  7),  and,  holding  the  scissors  vertically  from 
above  downward  near  the  wall  of  the  sac,  make  several  cuts  in  front 
and  to  both  sides.  These  incisions  will  at  once  free  the  path  to  the 
beginning  of  the  naso-lachrymal  duct.  Finally,  the  vertically  held 
scissors  are  pushed  down  into  the  bony  portion  of  the  duct  from  the 
anterior  or  lateral  surface,  and  in  this  manner  the  sac  is  cut  through. 
While  the  assistant  -tampons  the  wound,  I  put  the  sac  over  a  Bow- 
man's probe  to  convince  myself  of  the  intactness  of  its  wall,  believed 


FIG.  8. — Operative  Field  after  Completed  Excision. — The  small  portion  of  the  deep  fascia, 
which  has  been  left  behind,  is  seen  hanging  to  the  anterior  lachrymal  crest;  on  it  the  trans- 
verse incision  (i)  is  still  visible.  The  saccal  fossa  (f.  s.)  is  quite  empty.  The  outer  border 
is  formed  by  the  deep  fascia  (f.  p.)  where  it  is  firmly  attached  to  the  posterior  lachrymal 
crest;  it  is  of  a  white  color  and  has  a  distinct  luster.  Behind  the  anterior  crest  is  the  probe, 
which  passes  through  the  duct  into  the  nose. 

to  be  removed  as  a  whole.  If  the  stenosis  present  is  complete,  the  sac 
will  have  the  appearance  of  a  closed  cyst.  The  mucous  membrane 
is  brought  to  view  only  after  the  sac  has  been  cut  open.  If  we  now 
examine  the  wound  cavity  (Fig.  8),  and  this  should  never  be  omitted, 
we  will  see  as  the  median  boundary  the  lachrymal  crest  and  the  bony 
lachrymal  fossa,  deprived  of  its  periosteum;  and  as  the  lateral  wall  the 
dense,  white,  smooth,  glistening  deep  fascia  (the  posterior  branch  of 
the  internal  ligament  of  the  canthus),  which  completely  separates  the 
wound  from  the  orbit.  The  sac  does  not  properly  lie  within  the  orbital 
cavity,  but  rather  outside  it. 


12  OPHTHALMIC    SURGERY. 

If  during  the  operation,  the  surgeon  loses  his  bearings  and  dissects 
toward  the  orbit,  the  connective  tissue  septum  is  usually  injured  and 
considerable  disturbance  is  produced  by  the  orbital  fat  entering  the 
wound.  This  fat  prevents  a  good  view  of  the  operative  field,  and  retards 
the  operation  considerably  by  the  hemorrhage  which  results  when  it  is 
cut  away. 

Finally,  we  must  introduce  a  Bowman's  probe  into  the  naso- 
lachrymal  duct.  To  find  its  opening  we  place  the  instrument  verti- 
cally against  the  bone  immediately  behind  the  anterior  lachrymal  crest 
and  push  it  downward.  Should  the  passage  be  closed,  the  instrument 
must  be  forced  through  the  cicatricial  tissue.  In  every  instance  this 
passage  must  be  enlarged  with  a  sharp  curette,  and  all  the  mucous 
membrane  found  in  the  duct  scraped  away.  Curettment  of  the 
cavity  which  contained  the  sac  is  not  only  unnecessary,  if  the  sac  has 
been  excised  properly,  but  even  superfluous.  The  naso-lachrymal 
duct  is  opened  with  the  probe  in  every  case  and  made  perfectly  patulous 
by  curettment,  not  only  to  prevent  any  possible  secretion  from  its 
mucous  membrane,  but  also  to  provide  drainage  for  the  wound. 
Before  closing  the  wound  with  sutures,  it  must  be  washed  out  with  a 
weak  corrosive  sublimate  solution,  care  being  taken  that  the  fluid  will 
not  enter  the  opened  naso-lachrymal  duct  and  through  it  reach  the 
mouth  of  the  patient. 

The  sutures  should  receive  especial  attention.  The  skin  of  the 
neighborhood  is  thin,  often  easily  torn,  and  usually  curled  up  at  the 
margins  of  the  wound.  If  the  edges  of  the  skin  are  not  perfectly 
apposed,  primary  union  is  impossible,  and  the  relatively  large  wound 
must  fill  in  by  granulation.  This  means  not  only  a  retardation  of  the 
healing  process,  but  also  a  broader  and  more  conspicuous  scar,  while 
the  delicate  scar  following  a  w^ell  applied  suture  and  healing  by  first 
intention  is  often  hardly  visible. 

Three  sutures  suffice,  if  the  wround  is  of  the  usual  length;  if  shorter 
than  usual,  perhaps  only  two.  Thin  silk  is  the  best  material  for  the 
purpose.  Small  hooks,  sharp  and  somewrhat  bent,  are  inserted  into 
both  the  upper  and  lowrer  wound-angle,  and  the  wound  somewhat 
stretched;  the  thin,  sharply  curved  needles  containing  the  thread  are 
then  pushed  through  near  the  margins  of  the  wround.  The  assistant 
must  then  adapt  both  margins,  which  are  usually  curled  up  consider- 
ably, with  two  pairs  of  forceps,  so  that  margin  apposes  margin.  He 
then  turns  the  forceps  to  one  side,  so  that  the  operator,  who  holds  the 


THE    LACHRYMAL    APPARATUS.  13 

looped  threads  parallel  to  the  wound,  can  apply  the  knot  readily  at  the 
side  of  the  wound.  The  knots  should  not  be  drawn  too  tightly,  but 
only  enough  to  maintain  perfect  adaption,  as  the  silk  readily  cuts 
through  the  skin,  which  at  this  point  is  easily  lacerated.  The  threads 
must  then  be  cut  short. 

Before  applying  the  dressing,  the  intactness  of  the  corneal  surface 
must  be  investigated.  I  have  already  called  attention  to  the  danger 
of  an  accidentally  produced  corneal  erosion.  The  application  of 
the  dressing  demands  great  care.  The  closed  eye  must  first  be  covered 
with  a  small  pad  of  gauze.  This  prevents  the  threads  from  other 
parts  of  the  dressing  passing  through  the  palpebral  fissure  and  eroding 
the  cornea.  The  wound  is  then  covered  with  a  tightly  rolled  pad  of  iodo- 
form-gauze,  which  is  pressed  slowly  and  with  gradually  increasing 
force  against  the  wound,  so  that  the  wound-cavity  is  completely  oblit- 
erated. A  second  small  pad  made  of  sterile  gauze  is  placed  on  top 
of  the  iodoform  gauze.  This  ensures  permanent  compression.  The 
entire  eye  is  then  covered  with  a  few  layers  of  white  gauze,  and  the 
entire  dressing  secured  with  a  strip  of  adhesive  plaster,  which  should 
be  drawn  tightly.  Lastly  the  bandage  is  applied.  The  other  eye 
remains  open. 

On  the  following  day  the  dressing  is  removed  for  the  purpose  of 
inspecting  the  cornea.  The  compression-pad,  however,  is  not 
removed  from  the  wound,  the  outer  angle  of  the  palpebral  fissure  being 
opened  but  slightly  with  the  fingers.  If  the  case  progresses  satisfactor- 
ily, the  second  change  in  dressings  is  not  made  until  the  third  day. 
On  the  fourth  day  the  dressing  is  taken  off,  the  stitches  removed,  the 
wound  healing  by  first  intention.  Should  the  suture-openings  bleed 
slightly,  it  will  suffice  to  dust  them  with  xeroform  or  to  close  them  for  a 
day  with  adhesive  plaster. 

If,  however,  blood  has  collected  in  the  wound-cavity,  the  progress  of 
the  healing  of  the  wound  is  retarded.  The  cause  of  the  accumulation 
of  blood  is  nearly  always  incomplete  compression  of  the  wound.  In 
this  complication  the  patient  complains  of  pain  within  a  day  or  two 
after  the  operation,  and  upon  removal  of  the  dressings  the  wound  is 
found  to  be  bulging,  and  the  skin  dusky  red  and  tender  to  the  touch. 
The  best  treatment  is  to  remove  the  sutures,  and  to  forcibly  open  the 
wound  with  a  sharp  sound  or  probe,  so  as  to  afford  free  drainage  for 
the  accumulated  fluid.  A  small  drain  of  iodoform  gauze  should  be 
inserted  and  a  moist  antiseptic  dressing  applied. 


14  OPHTHALMIC    SURGERY. 

Although  this  complication  is  annoying,  it  is  usually  found  that 
in  the  course  of  a  few  days  the  wound  fills  with  granulations  and  cica- 
trizes in  a  short  time. 

It  is  an  entirely  different  matter,  however,  if  the  inflammation  and 
accumulation  are  due  to  retained  particles  of  mucous  membrane 
of  the  sac — in  other  words,  if  the  excision  has  been  incomplete. 
This  may  happen  occasionally  to  the  most  experienced  operator;  in  the 
case  of  beginners  it  is  not  at  all  a  rare  occurrence. 


CHAPTER  II. 

THE    LACHRYMAL    APPARATUS     (Continued). 
EXCISION  OF  THE  LACHRYMAL  SAC  (Continued). 

Before  considering  the  complications  which  may  arise  in  the  perform- 
ance of  resection  of  the  lachrymal  sac  it  is  necessary  to  discuss  the 
proper  method  of  making  the  operative  area  anesthetic  and  anemic. 
Practically  all  descriptions  of  this  operation,  refer  to  the  extraordinarily 
profuse  bleeding,  which  obscures  the  field  of  operation  and  makes  the 
dissection  more  than  ordinarily  difficult.  It  is  also  generally  noted 
that  cocain  does  not  produce  a  sufficient  analgesia,  so  that  many  opera- 
tors prefer  to  remove  the  sac  under  general  anesthesia.  The  employ- 
ment of  adrenalin,  however,  has  produced  a  complete  revolution  in 
this  respect,  and  today  the  operation  may  be  made  almost  bloodless 
and  painless. 

The  following  preparatory  measures  are  recommended: 

After  the  conjunctival  sac  has  been  rendered  anesthetic  by  a  few 
drops  of  3  per  cent,  cocain-solution,  the  lower  lachrymal  duct  is  dilated 
with  a  conical  probe  and  a  i  per  cent,  solution  of  cocain  is  injected  into 
the  sac  by  means  of  a  lachrymal  syringe.  To  prevent  the  fluid  from 
flowing  into  the  nose  and  eventually  into  the  mouth,  the  patient  should 
be  placed  in  a  sitting  position  with  the  head  bent  slightly  forward. 
In  most  instances  the  fluid  will  escape  through  the  lachrymal  ducts,  par- 
ticularly the  upper.  This  preliminary  procedure  not  only  anesthetizes 
but  also  cleanses  the  sac,  which  is  of  decided  advantage,  for,  although 
the  sac  itself  is  not  injured  during  the  operation,  the  lachrymal  and  naso- 
lachrymal  ducts  are  cut  through,  and  the  contained  secretion  may 
escape  and  contaminate  the  wound.  But  even  in  such  cases,  in  my 
experience,  infection  of  the  wound  is  of  rare  occurrence,  and  should  it 
occur,  it  is  nearly  always  of  light  character,  never  becoming  serious. 

The  technic  of  the  operation  is  as  follows:  The  contents  of  a 
Pravaz's  syringe  of  i  cc.  capacity  will  be  sufficient  quantity  for  the 
injection.  The  solution  is  mixed  in  the  following  manner:  8  to  9  parts 
of  the  syringe  are  filled  with  the  i  per  cent,  cocain-solution,  the 
remainder,  from  i  to  2  parts,  filled  with  adrenalin  or  suprarenin  solu- 

15 


1 6  OPHTHALMIC    SURGERY. 

tion  (i-iooo).  One-third  of  the  contents  of  the  syringe  is  injected 
beneath  the  skin,  the  needle  entering  slightly  below  the  tarsal  ligament. 
This  produces  a  slight  bulging  forward  of  the  lachrymal-sac  region, 
but  slight  massage  causes  the  immediate  disappearance  of  this  swelling. 
The  point  of  the  needle  is  now  inserted  above  the  tarsal  ligament  and 
pushed  vertically  against  the  bone.  The  syringe  is  then  twisted  for- 
ward 90°  so  that  the  needle  is  turned  in  the  direction  of  the  orbit.  Hold- 
ing it  in  this  direction  the  point  is  pushed  forward  to  very  near  the  peri- 
osteum and  the  second  third  of  the  solution  injected,  so  that  the  tissue 
around  the  top  of  the  lachrymal  sac  is  made  anesthetic  and  anemic  from 
this  injection.  With  the  remaining  solution  the  region  immediately 
about  the  entrance  into  the  naso-lachrymal  duct  is  anesthetized. 
The  injection  is  made  in  a  manner  similar  to  that  previously  described. 
The  needle  is  inserted  below  the  tarsal  ligament  in  a  direction  vertical 
to  the  lachrymal  crest;  the  syringe  is  then  turned  in  such  a  manner 
that  the  needle  lies  parallel  to  the  bone,  when  it  is  pushed  slightly 
backward.  Should  the  point  of  the  needle  enter  the  lachrymal  sac 
itself,  it  must  be  pulled  out  somewhat  and  turned  in  a  slightly  different 
direction.  This  complication  is  readily  recognized  by  the  escape  of 
fluid  from  the  tear-ducts. 

Immediately  after  completing  the  injection,  the  operation  may  be 
commenced.  In  a  large  majority  of  cases,  the  bleeding  is  so  slight  that 
layer  after  layer  of  tissue  may  be  removed  as  in  the  dissection  of  a 
cadaver.  I  have  frequently  resected  lachrymal  sacs  in  a  few  minutes 
without  any  assistance.  It  is  really  only  the  incision  through  the  skin 
which  may  bleed  more  than  expected,  as  occasionally  the  skin  contains 
abnormally  large  veins.  The  deeper  parts  are  always  absolutely 
anemic. 

The  stated  quantity  of  adrenalin  (y1^  to  y2^  cc.)  suffices  fully  for  the 
production  of  this  anemia.  In  my  experience  it  has  never  been 
followed  by  bad  after-results,  either  local  such  as  marked  secondary 
hemorrhage  or  necrosis  of  the  tissue,  or  constitutional.  Occasionally  a 
patient  may  complain  of  sudden  distress,  such  as  a  sensation  of  oppres- 
sion and  palpitation  of  the  heart,  but  these  symptoms  disappear  shortly. 
In  elderly  patients  with  advanced  arteriosclerosis,  not  more  than 
TV  cc.  of  the  adrenalin  should  be  injected,  and  this  amount  will  be 
sufficient.  Dropping  the  adrenalin  into  the  wound  is  unsatisfactory. 
After  the  sac  has  been  peeled  out,  and  before  the  probe  is  inserted  into 
the  nose,  some  cocain  should  be  dropped  into  the  wound.  It  will 


THE    LACHRYMAL    APPARATUS.  1 7 

diffuse  itself  into  the  duct  along  the  probe,  and  will  make  the  curettment 
with  the  sharp  spoon  almost  painless. 

Complications. — The  proper  resection  of  the  lachrymal  sac  is  one  of 
the  most  difficult  operations  in  ophthalmology.  The  difficulty,  espe- 
cially for  the  beginner,  lies  in  finding  the  sac.  Of  course,  this  refers 
only  to  cases  in  which  the  sac  has  not  become  so  distended  as  to  be 
visible  as  a  tumor  through  the  skin.  The  anterior  lachrymal  crest 
must  always  serve  as  a  landmark  throughout  the  entire  operation;  and 
the  operator  should  always  keep  as  dose  as  possible  to  the  bone.  He 
will  then  refrain  from  looking  for  the  sac  too  near  the  nose  in  the  per- 
iosteum of  the  bone,  and  also  avoid  penetrating  the  orbital  tissue  with 
H'hich  he  should  never  even  come  in  contact. 

The  opening  of  the  orbital  cavity,  through  injury  to  the  dividing 
fascia,  becomes  dangerous  at  times,  as  it  may  terminate  in  infection  of 
the  orbit  and  formation  of  an  orbital  abscess,  though  ordinarily  it  is 
disadvantageous  only  because  of  the  protrusion  of  fat  and  hemorrhage 
from  the  orbital  tissues.  The  beginner  enters  the  orbit  quite  often,  not 
from  injury  to  the  fascia,  but  because  he  fails  to  work  toward  the  crest, 
and  he  dissects  backward  and  penetrates  the  fat  of  the  orbit  on  the 
outer  side  of  the  fascia,  without  ever  having  cut  into  it.  In  so  doing 
he  naturally  does  not  find  the  lachrymal  sac. 

Should  the  sac  be  injured  during  the  operation  no  importance  need 
be  attached  to  the  accident,  provided  the  operator  sees  his  mistake  at 
once  and  returns  to  dissect  at  the  proper  point.  It  may  happen  that 
during  the  opening  of  the  deep  fascia  (especially  if  done  quickly)  not 
only  the  fascia  but  also  the  anterior  wall  of  the  sac,  which  lies  imme- 
diately beneath  it,  is  slit  open.  If  the  operator  is  not  aware  of  the 
accident,  he  may  dissect  off  only  the  anterior  half  of  the  wall,  thinking 
that  he  has  the  entire  sac  before  him.  If  he  is  sufficiently  careful, 
however,  and  notes  the  injury,  he  can  retrace  his  steps  and  without 
much  difficulty  find  the  right  spot  for  continuance  of  the  dissection  on 
the  outer  side  of  the  sac  wall.  The  cleaner  the  dissection  of  the  sac,  i.e., 
the  closer  to  the  wall  of  the  sac  the  operator  keeps,  by  constantly  dis- 
secting between  it  and  the  covering  fascia,  the  more  satisfactory  will 
be  the  course  of  the  operation.  It  is  remarkable  with  what  perfect 
freedom  from  hemorrhage  and  pain  the  operation  may  be  performed. 
The  operator  who  lacks  sufficient  knowledge  concerning  the  exact 
position  and  surroundings  of  the  sac,  and  resects  it  together  with  all 
the  attached  tissues  so  as  to  be  certain  to  have  the  sac  in  the  excised 


1 8  OPHTHALMIC    SURGERY. 

portion,  will  be  greatly  annoyed  by  hemorrhage,  and  his  patient  will 
suffer  much  pain. 

Even  the  experienced  operator  may  fail  occasionally  in  extirpating  the 
sac  in  one  piece  and  may  remove  it  in  several  portions.  This  may  be 
considered  as  practically  a  failure,  as  small  particles  of  the  mucous 
membrane  are  retained,  which  could  cause  continuance  of  the  dis- 
charge or,  still  more  unpleasant  for  the  patient,  lead  to  formation  of  a 
fistula.  The  causes  of  such  a  disappointing  result  may  be  an  excep- 
tionally profuse  hemorrhage,  preventing  accurate  dissection,  tearing  of 
the  sac  during  operation,  or,  finally,  the  partial  destruction  of  the  ante- 
rior wall  of  the  sac,  the  dacryocystitis  having  produced  a  rupture  into  the 
surrounding  tissue  without  having  gone  so  far  as  perforation  of  the  skin. 

The  beginner  finds  more  difficulty  in  the  resection  of  the  lateral 
than  of  the  median  wall,  since  in  removing  the  latter  he  need  only  keep 
close  to  the  bone.  It  is  also  quite  a  common  error  to  sever  the  sac  some 
distance  below  the  apex,  leaving  this  portion  behind,  since  the  top  is 
closely  adherent  to  the  fascia  covering  it  and  must,  therefore,  be 
removed  with  the  sharp  edge  of  the  scissors.  The  importance  of  inspect- 
ing the  wound  carefully  after  an  entire  removal  of  the  sac,  to  note 
whether  or  not  the  bone  is  healthy,  is  especially  great  in  instances  in 
which  a  part  of  the  sac  has  been  left  behind.  Curetting  blindly  with 
the  sharp  spoon  is  not  only  a  crude  procedure,  but  entirely  without 
value. 

If  parts  of  the  sac  have  been  left  behind,  the  wound  should 
be  well  packed,  the  best  material  being  tannin-iodoform  gauze,  and 
further  operation  deferred  until  the  bleeding  has  been  checked  com- 
pletely. The  wound  is  then  held  widely  open  with  the  speculum, 
and  a  careful  examination  made.  In  most  instances  it  wrill  not  be 
difficult  to  see  the  parts  of  the  wall  which  have  been  left  behind  and 
these  must  be  grasped  with  forceps  and  carefully  separated  from 
underlying  fascia  and  bone.  It  is  only  by  removing  all  the  remaining 
mucous  tissue  that  a  cure  and  healing  by  first  intention  can  be  expected. 

If  the  wound  is  sutured  over  retained  particles  of  mucous  membrane, 
primary  union  is  prevented.  Within  a  short  time  the  wound  is  dis- 
tended by  secretion,  and  the  sutures  rupture,  or  must  be  removed  to 
allow  escape  of  the  retained  secretion,  otherwise  persistent  suppura- 
tion will  be  the  inevitable  result.  In  the  event  of  suppuration  the 
wound  must  be  loosely  packed  with  iodoform-gauze  and  washed  with 
weak  bichlorid  solution  or  a  6  per  cent,  solution  of  hydrogen  peroxid. 


THE    LACHRYMAL    APPARATUS.  19 

To  at  once  curette  the  wound  is  an  error,  as  it  is  impossible  during  the 
period  of  granulation  to  recognize  all  the  details  of  the  wound.  Even 
though  the  sharp  curette  is  thoroughly  employed,  the  discharge  will  not 
cease.  The  mucous  membrane  attached  to  the  bone  may  be  removed 
by  the  operator,  but  that  of  the  lateral  wall,  not  having  firm  tissues 
beneath  it,  always  escapes  the  sharp  instrument. 

The  skillful  operator  will  often  have  occasion  to  dissect  the  entire 
lateral  wall  and  top  of  the  lachrymal  sac  of  patients  who  were  treated 
without  success  by  repeated  curettings,  and  will  have  no  difficulty  in 
effecting  an  instantaneous  cure  by  primary  union. 

Under  such  circumstances  the  preparation  for  extirpation  is  more 
difficult  than  in  those  cases  in  which  the  tissues  are  still  untouched. 
Even  in  such  cases  it  should  be  the  aim  of  the  operator  to  remove  layer 
after  layer,  at  least  as  far  as  possible  in  the  scar-tissue,  instead  of  fol- 
lowing the  usual  practice  of  cutting  down  in  the  first  incision  to  the 
anterior  lachrymal  crest. 

The  anemia  produced  by  the  cocain-adrenalin  infiltration  in  the 
dense  scar-tissue  is  here  of  decided  advantage,  as  it  permits  the  operator 
to  see  every  step  of  the  operation  very  clearly.  The  bluish  color  of  the 
mucosa  readily  differentiates  it  from  the  white  of  the  scar-tissue,  and  in 
most  instances  it  can  be  peeled  off  very  easily.  This  is  then  followed 
by  a  close  scrutiny  of  the  wound  to  be  assured  that  all  the  lining  has 
been  removed,  and  then,  as  in  a  completely  performed  excision  of  the 
lachrymal  sac,  the  wound  is  closed  by  sutures. 

The  operation  becomes  still  much  more  difficult,  if  either  after 
attempted  extirpation  or  after  dacryocystitis  a  fistula  has  developed. 
In  such  cases  one  has  to  perform  a  long  incision  (2  cm.)  so  that  the 
fossa  may  be  conveniently  reached.  The  fistula  must  be  completely 
excised.  The  incision,  which  at  first  is  only  through  the  skin,  is  at 
once  deepened  to  the  crest  after  the  wound-edges  have  been  dissected 
up  and  the  wound  well  stretched  with  the  speculum.  The  entire  fossa 
is  now  cleaned  out,  thus  excising  all  of  the  exposed  scar-tissue.  Very 
often  the  lateral  fascial  boundary  can  be  found,  so  that  after  com 
pleting  the  operation  there  is  presented  the  usual  picture  of  the 
wound,  i.e.,  the  median  border  formed  by  the  bone  with  its  promi- 
nent crest  and  the  lateral  border  by  the  fascia.  Even  in  these  cases 
it  is  not  advisable  to  use  the  curette,  but  prove  by  close  inspection  of 
the  wound  that  none  of  the  mucous  membrane  has  been  forgotten. 
Suturing  the  wound  is  unfortunately  often  impossible,  as  the  skin, 


20  OPHTHALMIC    SURGERY. 

particularly  if  several  attacks  of  dacryocystitis  have  preceded  the  oper- 
ation, is  easily  torn.  By  packing  the  wound  loosely,  the  rapid  devel- 
opment of  granulations  is  favored,  and  the  cavity  will  soon  fill  up. 
Even  after  such  an  operation  the  scar  may  be  remarkably  insignificant. 
It  is  not  uncommon  for  the  repeated  mistreatment  of  the  tissues  to 
result  in  a  ectropion  through  shrinking  of  the  scar.  In  these  cases 
success  in  elevating  the  lid  and  retaining  it  permanently  in  its  proper 
position  has  been  achieved  by  sutures  going  obliquely  through  the 
wound-edges  from  without  inward  and  from  below  upward. 

If  there  is  great  dilatation  of  the  lachrymal  sac,  which,  acting  like 
a  tumor,  pushes  the  skin  forward,  the  operation  cannot  be  performed  by 
the  rules  laid  down.  The  tissues  covering  the  sac  may  be  so  atrophic 
that  immediately  after  cutting  through  the  skin  the  wall  of  the  sac 
may  be  exposed.  In  other  respects,  however,  the  removal  of  the  sac 
does  not  differ  in  the  slightest  from  that  of  other  tumors  in  this 
region.  If  proper  care  is  taken  not  to  injure  the  sac,  successful  oper- 
ation is  easy. 

Tuberculous  disease  of  the  lachrymal  sac,  especially  as  seen  in 
children,  makes  a  radical  operation  difficult,  as  the  wall  of  the  sac  is 
frequently  destroyed  through  tuberculous  infiltration  which  may 
implicate  the  bone.  The  diseased  tissue  must  then  be  cut  away,  the 
diseased  bone  removed,  and  the  wound  packed  with  iodoform  gauze 
and  permitted  to  heal  by  granulation.  Recurrence  is  common  in  this 
type  of  disease,  and  is  usually  accompanied  by  formation  of  fistuke, 
which  then  make  secondary  operations  necessary. 

If  an  acute  dacryocystitis  exists,  no  incision  is  made  unless 
perforation  seems  unavoidable.  Otherwise  we  must  be  satisfied 
with  applying  moist  antiseptic  dressings  and  must  wrait  patiently  until 
the  inflammation  has  completely  disappeared,  a  matter  of  several 
weeks.  Then  the  extirpation  of  the  sac  must  take  place  to  prevent 
the  inflammation  recurring.  Formerly  in  such  cases,  the  blood  vessels 
being  markedly  dilated,  profuse  hemorrhage  was  the  rule  during  the 
operation;  this  can  now  be  completely  avoided  by  the  method  of  injec- 
tion already  given. 

The  Indications  for  the  Resection  of  the  Lachrymal  Sac. — This 
operation  is  absolutely  indicated:  i.  In  all  cases  of  chronic  blenor- 
rhea  of  the  lachrymal  sac,  which  lead  to  marked  thickening  of  its  walls 
and  eventually  to  its  dilatation,  to  total  obstruction  of  the  naso-lachry- 
mal  duct,  or  to  the  formation  of  a  fistula.  2.  When  an  operation 


THE    LACHRYMAL    APPARATUS.  21 

(iridectomy,  extraction  of  a  cataract,  etc.)  is  to  be  performed  on  the  eye 
of  the  corresponding  side.  3.  When  a  purulent  infiltration  of  the 
cornea  has  taken  place  (infected  erosion,  ulcus  serpens,  etc.).  Cauteri- 
zation of  such  an  ulcer  would  not  bring  about  the  desired  result  as  the 
discharge  from  the  diseased  sac  would  constantly  flow  over  the  denuded 
area  and  through  its  microorganism  produce  new  infections.  4.  In 
all  cases  coming  to  the  dispensary,  as  these  patients  have  not  the  time 
for  a  long  course  of  treatments  with  sounds,  and  at  best  this  method 
usually  promises  but  indifferent  results.  Particularly  is  resection 
recommended  if  the  treatment  with  probes  has  previously  been  carried 
out  withouc  substantial  improvement. 

The  ultimate  result  of  the  resection-operation  is  very  satisfactory. 
In  a  very  short  time  the  scar  is  hardly  visible,  the  catarrh  constantly 
associated  with  the  blenorrhea  soon  disappears,  and  with  it  also  the 
lachrymation,  the  latter  probably  through  a  nervous  influence.  Should 
the  catarrh  and  epiphora  persist  after  the  operation,  a  careful  examina- 
tion should  be  made  of  the  canaliculi,  and  if  a  slight  amount  of  mucopu- 
rulent  discharge  can  be  squeezed  from  them,  it  is  a  sign  that  some 
mucous  membrane  has  been  left  behind.  If  there  is  no  discharge  and 
the  lachrymation  continues  for  several  months  after  the  operation, 
the  lower  lachrymal  gland  must  be  resected. 


CHAPTER  III. 
THE  LACHRYMAL  APPARATUS  (Continued). 

EXCISION  OF  THE  PALPEBRAL  LACHRYMAL  GLAND. 

This  operation  is  performed  in  those  occasional  cases  in  which  the 
watering  of  the  eyes  does  not  disappear  spontaneously.  When  patients 
living  at  a  distance  require  removal  of  the  lachrymal  sac,  it  is  often  best 
to  simultaneously  resect  the  lachrymal  gland;  this  may  possibly  save 
the  patient  a  second  journey.  Lachrymation  from  other  causes  may 
also  indicate  the  operation. 

The  palpebral  portion  of  the  lachrymal  gland  is  understood  to  indi- 
cate that  lobule  of  gland-substance  which  surrounds  the  excretory  ducts 
of  the  orbital  lachrymal  gland,  at  the  point  where  they  pass  toward 
and  through  the  superior  conjunctival  fornix.  This  so-called  infe- 
rior lachrymal  gland  may  be  seen  in  many  individuals  by  lifting  or  evert- 
ing the  upper  lid  at  its  outer  part,  while  the  patient  is  looking  downward 
and  inward;  sometimes  it  bulges  forward  in  the  form  of  a  small  lobu- 
lated  tumor.  To  reach  the  gland  conveniently,  the  lid  must  be 
everted  twice.  This  is  done  best  by  first  everting  the  lid  with  the 
finger  in  the  usual  manner,  then  inserting  an  opened  lock-forceps  at 
the  junction  of  the  outer  and  middle  thirds  in  such  a  manner  that  one 
blade  is  pushed  beneath  the  lid  into  the  conjunctival  fornix,  the  other 
lies  anteriorly  on  the  tarsus.  The  lock  is  slowly  closed  and  the  lid 
everted  the  second  time  by  turning  the  forceps  slowly  upw-ard. 

If  the  conjunctival  sac  has  been  well  cocainized  at  the  outset,  the 
resection,  carefully  performed,  is  not  painful.  One-third  c.c.  of  a  i 
per  cent,  solution  of  cocain  should  be  injected  under  the  conjunctiva; 
the  injection  is  best  made  into  the  tissues  between  the  point  of  the  for- 
ceps and  the  external  canthus.  The  operation  itself  is  not  difficult, 
but  it  must  be  performed  carefully  if  the  gland  is  to  be  resected  in  one 
piece,  and  not  cut  away  in  a  number  of  fragments. 

The  first  step  in  the  operation  is  to  make  an  incision  through  the 
conjunctiva  with  a  small  pair  of  curved  scissors;  this  should  extend 
horizontally  from  the  point  of  the  forceps  toward  the  external  canthus 
for  a  distance  of  about  i  cm.  The  lobules,  which  may  be  numerous 

22 


THE    LACHRYMAL    APPARATUS. 


23 


and  well  developed,  at  other  times  few  and  small,  protrude  through 
the  wound  as  soon  as  the  connective-tissue  membrane  which  encap- 
sulates the  lachrymal  gland  is  opened.  (The  cocain-injection  may 
obscure  the  outlines  of  the  structures  at  this  time.)  The  next  step 
is  to  carefully  dissect  the  conjunctiva  loose  both  in  an  upward  and 
downward  direction,  i.e.,  toward  the  tarsus  and  toward  the  ocular  con- 
junctiva. Of  considerable  aid  is  the  retraction  of  both  portions  of  the 
conjunctiva  by  the  assistant  with  a  double  tenaculum.  The  lachry- 
mal gland  will  finally  be  seen  as  a  small  node  in  the  center  of  the 


FIG.  9. — Extirpation  of  the  lachrymal  gland.  The  upper  lid  is  turned  upward  twice — 
i.e.,  upon  itself — and  is  maintained  in  this  position  by  a  lock  pincette  held  by  an  assistant 
at  the  outer  third  of  the  lid.  The  conjunctiva  (c)  is  freed  on  both  sides  of  the  gland.  The 
wound  is  held  open  with  double  tenacula.  In  it  is  seen  lying  perfectly  free  the  lower 
lachrymal  gland  (gl.)>  appearing  as  a  small  nodule. 


wound  (Fig.  9).  The  gland  is  now  grasped  with  forceps  and 
separated  from  the  orbital  lachrymal  gland  with  cuts  of  the  scissors, 
beginning  at  the  nasal  end.  It  is  not  necessary  to  dissect  high  up  into 
the  orbit,  but  it  is  important  that  the  lobules  are  shelled  out  for  their 
entire  length,  as  only  then  can  all  the  excretory  ducts  of  the  large  gland 
be  cut  through.  The  amount  of  glandular  substance  removed  during 
this  is  of  no  moment  whatever.  The  white  membrane  laid  bare  in  the 
floor  of  the  wound  is  the  tarso-orbital  fascia.  It  must  not  be  injured. 
It  lies  in  front  of  the  gland  and  does  not  interfere  with  its  extirpation. 


24  OPHTHALMIC    SURGERY. 

Its  injury  might  have  added  unpleasant  consequences  on  account  of  its 
connection  with  the  tendon  of  the  levator  palpebrae  and  the 
possibility  of  resultant  ptosis.  Fastening  of  the  forceps  at  the  outer 
third  of  the  lid,  as  ordered  above,  will  prevent  such  occurrence,  even  if 
the  dissection  is  carried  too  deep  and  the  fascia  cut  into  and  injured. 
An  injury  to  the  outer  skin  or  the  external  rectus  muscle  can  be  produced 
only  by  reckless  cutting;  this  is  clearly  apparent  if  the  position  of 
the  gland  is  considered.  The  hemorrhage  during  the  operation  is 
slight,  although  usually  disturbing,  and  the  assistant  is  kept  busy  spong- 
ing up  the  blood. 

One  catgut  suture,  bringing  the  wound  together  from  above  down- 
ward, suffices,  and  the  dressing  may  be  removed  after  twenty-four 
hours.  After  the  operation  the  eye  is  usually  ecchymotic  for  some 
days  on  account  of  the  blood  subsiding  to  the  lower  levels.  Slight  swell- 
ing of  the  upper  lid  produces  some  ptosis,  but  this  disappears  soon.  The 
result  of  the  operation  is  generally  good,  even  though  occasionally 
lachrymation  is  but  little  diminished.  In  one  such  case,  even  though 
the  operation  was  performed  according  to  every  rule  mentioned, 
weeping  persisted  to  such  a  degree  that  it  became  necessary  to  remove 
the  orbital  lachrymal  gland  itself.  This  operation  must  be  per- 
formed through  an  incision  from  the  skin. 

Dryness  of  the  conjunctiva  or  the  cornea  need  not  be  feared  either 
after  extirpation  of  the  inferior  or  the  entire  lachrymal  gland,  as  the 
glandular  secretion  of  the  normal  conjunctiva  is  sufficient  to  prevent 
this.  However,  after  extirpation  of  the  lachrymal  gland,  an  obstinate 
and  long-lasting  catarrh  of  the  conjunctiva  associated  with  thick  mucoid 
discharge  is  occasionally  to  be  seen. 

LACHRYMAL   PROBING. 

Dilatation  of  the  Canaliculus. — Before  attempting  to  pass  a 
Bowman's  probe,  the  lachrymal  canaliculus  must  be  dilated.  This  is 
done  with  a  conical  probe.  Its  first  position  is  vertical  to  the  inferior 
lachrymal  canaliculus  (Fig.  10).  Before  placing  it  in  this  position  the 
patient  is  asked  to  look  up  and  the  lower  lid  is  pulled  outward  and 
slightly  away  from  the  bulb,  thus  making  the  lid  tense.  The  lachry- 
mal canaliculi  at  first  pass  for  a  short  distance  downward,  then  gradually 
upward  and  finally  describe  an  almost  right  angle  to  empty  into  the 
lachrymal  sac.  To  dilate  the  left  canaliculus,  the  physician,  sitting 
in  front  of  his  patient,  employs  his  right  hand.  For  the  right  canalic- 


THE    LACHRYMAL    APPARATUS.  25 

ulus  the  left  hand  is  used,  or  the  surgeon  may  stand  behind  the  patient 
to  dilate  the  latter,  and  work  with  the  right  hand. 

After  the  point  of  the  vertically  applied  conical  probe  has  entered  the 
first  portion  of  the  lachrymal  canaliculus,  the  probe  is  depressed  into  a 
horizontal  position  and  then  pushed  slowly  forward,  employing  a 
slight  twisting  movement  until  the  bone  is  reached  (Fig.  n).  When 
lightly  drawing  the  probe  to  and  fro  does  not  cause  retraction  of  the  skin, 
we  know  that  its  point  has  passed  through  the  canaliculus  into  the 


FIG.  io.— Introduction  of  the  conical  probe  into  the  lower  lachrymal  canaliculus.  The 
lid  is  pulled  outward  with  one  finger,  and  the  lachrymal  punctum  thus  turned  slightly 
forward.  The  probe  is  inserted  vertically. 

lachrymal  sac  and  has  come  in  contact  with  its  median  wall.  The 
operator  must  be  careful  not  to  use  force  in  dilating  the  lachrymal  canal- 
iculus, as  the  point  of  the  probe  penetrates  the  wall  easily,  and  a  false 
passage  is  thus  made  that  makes  proper  probing  almost  impossible. 
Injury  of  the  lachrymal  canaliculus  or  the  wall  of  the  lachrymal  sac 
is  also  to  be  avoided,  because  during  subsequent  injection  of  cocain 
for  purposes  of  anesthesia  or  during  a  cleansing  of  the  sac  with  any 
antiseptic  or  astringent  solution,  the  fluid  diffuses  itself  through  the 


26 


OPHTHALMIC    SURGERY. 


subcutaneous  tissues,  producing  marked  swelling  of  the  structures  in 
the  neighborhood  of  the  lachrymal  sac,  as  well  as  of  the  lids. 

Through  the  insertion  of  the  conical  probe,  which  increases  in  size 
gradually,  the  mouth  of  the  lachrymal  canaliculus  is  so  far  enlarged 
that  every  number  of  the  blunt  Bowman's  probe  enters  easily.  The 
slitting  of  the  lachrymal  canaliculus  for  the  purpose  of  passing 
these  probes  is  not  necessary,  and,  therefore,  not  to  be  recommended. 
The  canaliculus  is  a  good  guide  for  Bowman's  probe  and  with  its  aid 
the  sac  is  always  easily  entered.  When  the  canaliculus  has  been  slit 
open,  it  may  become  very  difficult  to  find  the  beginning  of  the  portion 
which  has  been  left  intact  and  which  forms  the  point  of  entrance  to  the 


FIG.  ir. — Second  step  in  the  dilatation  of  the  lachrymal  canaliculus  with  the  conical 
probe.  The  probe  is'  placed  in  the  direction  of  the  canaliculus,  and  is  pushed  forward 
with  short  twisting  movements  to  the  median  wall  of  the  sac. 


lachrymal  sac.  Bitter  experience  has  shown  how7  fruitless  in  such 
cases  such  efforts  may  be,  as  occasionally  the  probe  cannot  be  passed 
at  all,  the  aperture  after  the  slitting  contracting  secondarily  through 
the  formation  of  delicate  scar  tissue  around  it.  There  is  usually  no 
difficulty  in  passing  a  No.  5  probe  through  the  intact  lachrymal 
canaliculus. 

Slitting  the  Canaliculus. — The  canaliculus  should  be  slit  only  if 
through  eversion  of  the  inferior  lachrymal  punctum  the  course 
of  the  tears  has  been  diverted  and  they  trickle  down  the  cheek,  or  if 
an  ectropion  of  the  lower  lid  has  begun  to  develop.  Slitting  the  lower 
canaliculus  converts  it  into  a  backwardly  directed  channel  which  com- 
municates freely  with  the  conjunctival  sac;  the  tears  are  thus  guided 
into  their  normal  path  and  one  of  the  main  causes  of  ectropion  is 


THE  LACHRYMAL  APPARATUS.  27 

removed.  This  operation  is  performed  with  a  Weber's  knife,  which 
is  inserted  into  the  dilated  canaliculus  and  pushed  in  until  the  probe 
point  of  the  knife  touches  the  bone.  The  cutting  edge  of  the  knife  is 
directed  upward  and  slightly  backward.  The  finger  pulls  the  lid  out- 
ward, making  it  tense,  and  the  knife,  the  probe  point  of  which  remains 
against  the  bone,  is  turned  up,  thus  cutting  the  lateral  part  of  the 
canaliculus.  The  hemorrhage  is  slight.  To  prevent  healing  together 
of  the  edges  of  the  wound,  they  must  be  separated  occasionally  during 
the  next  few  days  with  the  conical  probe,  until  the  epithelium  has  grown 
over  them. 

Probing  the  Duct. — For  purposes  of  probing  we  use  Bowman's 
probes,  Xos.  i  to  6.  The  point  of  the  probe  is  placed  vertically  into  the 
dilated  lachrymal  canaliculus,  and,  after  it  has  passed  the  lachrymal 
punctum,  its  direction  is  changed  to  the  horizontal,  the  skin  of  the  lid 
being  drawn  outward  at  the  same  time.  When  the  tip  of  the  probe 
strikes  the  bone,  the  lid  is  released  and  the  instrument  at  the  same  time 
returned  to  its  vertical  position.  With  a  slight  push  forward  the  probe 
glides  readily  into  the  naso-lachrymal  duct,  provided  there  are  no 
adhesions.  The  position  of  the  probe  in  the  upper  part  of  the  canal  is 
easily  recognized;  if  it  is  in  the  canal  it  will  remain  standing  when  the 
hand  is  taken  away,  it  falls  over  if  it  is  not  in  the  canal.  If  the  probe 
is  in  the  canal  for  a  certainty,  and  resistance  is  met  with  in  pushing  it 
forward,  slight  force  may  be  used  to  push  it  through  stenoses  and 
adhesions. 

If,  however,  wre  are  not  certain  that  the  probe  is  in  the  canal,  force 
should  never  be  used.  The  wall  of  the  lachrymal  sac  is  easily  perfor- 
ated, and  a  false  passage  into  the  surrounding  tissues  established.  It 
is  to  be  particularly  emphasized  that  the  re-establishment  of  the  probe 
in  its  vertical  position  and  its  gliding  into  the  naso-lachrymal  duct  are 
especially  difficult  for  the  beginner.  The  probe  is  frequently  pulled  out- 
ward a  little,  its  point  leaves  the  bone  and  gets  into  a  false  direction. 
The  conditions  are  especially  difficult  when  the  lachrymal  sac  is  almost 
completely  closed  off  by  adhesions.  If  the  beginner  is  not  absolutely 
certain  of  his  ground,  it  is  hard  to  decide  whether  force  may  be  at- 
tempted or  whether  a  false  passage  is  being  made.  If  the  probe  has  been 
inserted  properly,  its  plate  will  be  on  a  level  with  the  eyebrows  (Fig.  12) 
and  it  will  have  retained  the  slightly  curved  shape  and  position  into 
which  it  has  been  brought.  If  the  probe  has  entered  a  false  passage, 
it  can  be  recognized  by  the  abnormal  position  in  which  it  is  found. 


28  OPHTHALMIC    SURGERY. 

Ordinarily  the  rough  ends  of  the  perforation  in  the  bone,  through 
which  the  probe  has  been  pushed,  may  also  be  felt. 

Before  commencing  the  probing,  the  naso-lachrymal  duct  should 
be  made  anesthetic  with  an  injection  of  a  3  per  cent,  solution  of  cocain. 
The  best  instrument  for  this  purpose  is  Ariel's  syringe.  The  most 
suitable  model  has  a  ring  at  each  side;  the  second  and  third  fingers  are 
placed  in  these,  while  the  thumb  presses  the  piston  dowrn.  The  syringe- 
point  is  placed  upright  into  the  lachrymal  canaliculus,  is  then  changed 
to  a  horizontal  direction  and  pushed  into  the  lachrymal  sac  just  as  if  it 
were  a  probe.  In  this  position  the  fluid  flows  in  with  the  slightest 
pressure.  If  the  naso-lachrymal  duct  is  patulous,  a  small  amount  of 


FIG.  12. — Bowman's  probe  is  passed  through  the  naso-lachrymal  duct. 
The  small  plate  of  the  probe  is  on  a  level  with  the  eyebrow. 

fluid  will  slowly  run  from  the  nose  as  the  patient  bends  the  head  forward. 
If  considerable  resistance  is  felt,  the  fluid  should  not  be  forced  out  of 
the  syringe  under  too  great  pressure,  as  it  will  either  escape  through 
the  superior  lachrymal  canaliculus  or  it  will  be  forced  into  the  surround- 
ing tissues  from  the  lachrymal  sac,  setting  up  an  unpleasant  swelling 
of  the  lids  which  persists  for  several  days,  and  for  which  the  patient 
usually  blames  the  physician.  The  douching  of  the  lachrymal  sac 
should  never  be  performed  with  the  patient  lying  down,  especially 
if  the  fluid  is  a  cocain  or  bichlorid  solution;  as,  should  the  naso- 
lachrymal  duct  be  patulous,  the  fluid  will  flow  into  the  pharynx. 

The  probing  is  begun  with  No.  i,  and  is  repeated  every  second  or 
third  day,  the  size  of  the  probe  being  gradually  increased  until  No.  5 
is  reached.  It  is  well  to  remember  that  a  thick  probe  may  at  times 


THE  LACHRYMAL  APPARATUS.  29 

pass  by  a  fold  easier  than  a  thinner  instrument.  The  passage  of  the 
probe  may  be  considerably  facilitated  by  the  addition  of  a  small  amount 
of  adrenalin-solution  to  the  cocain.  This  contracts  the  blood-vessels 
in  the  wall  of  the  duct,  thus  increasing  its  lumen  and  with  it  the  space 
for  the  penetration  of  the  instrument.  The  probes  must  be  passed 
slowly  and  carefully,  and  slight  injuries  avoided,  as  these  give  rise  to 
the  formation  of  scar-tissue  and  through  it  to  new  stenoses.  The 
instrument  should  be  permitted  to  remain  in  the  naso-lachrymal  duct 
at  least  fifteen  minutes  each  time.  The  probing  must  be  continued 
until  the  fluid  from  Anel's  syringe  flows  easily  through  the  channel. 
Dilatation  to  probe  No.  5  usually  suffices.  If  the  weeping  continues 
it  may  be  considered  a  proof,  that  in  spite  of  the  normal  permeability 
of  the  lachrymal  canaliculus,  tear-conduction  and  possibly  even  tear- 
secretion  is  disturbed.  Tear-conduction  as  is  well  known,  is  not 
dependent  alone  on  the  normal  permeability  of  the  nasal  duct,  but  also, 
and  perhaps  to  a  greater  degree,  on  the  normal  activity  of  the  sac.  In 
such  cases  it  does  not  improve  the  patient  to  continue  the  ordinary 
probing  or  to  employ  the  larger  instruments. 

It  may  be  impossible  to  pass  probes  through  the  inferior  lachrymal 
canaliculus  in  the  manner  described,  owing  to  occlusion  by  scars 
following  burns  or  injuries.  The  probes  must  then  be  passed  through 
the  superior  canaliculus.  Its  course  is  analogous  to  that  of  the  lower; 
first  vertically  upward,  followed  by  a  curve  toward  the  sac.  After 
dilating  with  the  conical  probe,  cocain  is  injected  into  the  sac  with 
Anel's  syringe.  Bowman's  probe  is  inserted  in  the  direction  of  the 
naso-lachrymal  duct,  i.e.,  in  vertical  position. 

The  Passing  of  Probes  in  New-born  Children. — We  occasionally 
see  cases  in  which  the  secretion  is  retained  in  the  lachrymal  sac,  thus 
leading  to  considerable  dilatation.  This  is  the  result  of  a  congenital, 
but  only  epithelial,  occlusion  of  the  duct,  and  it  is  cured  by  one 
passage  of  a  small  probe.  The  operation  is  not  more  difficult  in  the 
new-born  than  in  the  adult,  but  it  must  be  remembered  that  the 
distance  between  lachrymal  point  and  nose  is  much  less  than  in  the 
adult,  and  therefore  the  probe  does  not  penetrate  as  great  a  distance. 

Indications  for  Probing. — If  the  constant  dripping  of  tears  makes 
the  existence  of  a  duct-stenosis  probable,  it  is  well  for  the  physician 
to  cocainize  the  conjunctiva,  dilate  the  canaliculus  with  the  conical 
probe  and  push  Anel's  syringe  cautiously  into  the  lachrymal  sac  to 
make  sure  of  the  diagnosis.  If  the  naso-lachrymal  duct  is  patulous, 


30  OPHTHALMIC    SURGERY. 

very  little  pressure  will  carry  the  fluid  through  into  the  nose  of  the 
patient,  as  he  holds  his  head  forward.  If  the  passage  is  narrow,  the 
fluid  will  not  flow  through  for  a  short  time,  and  then  only  in  small 
quantities,  while  the  greater  part  escapes  through  the  superior  lachry- 
mal canaliculus.  The  latter  occurs  if  the  lachrymal  sac  and  the 
naso-larchymal  duct  are  comlpetely  occluded.  Warning  has  already 
been  given  against  using  too  much  pressure,  so  as  not  to  force  the 
fluid  into  the  surrounding  tissues.  After  once  making  certain  that 
the  passage  is  narrow  or  completely  occluded,  the  probes  should  be 
employed  beginning  with  No.  2.  If  cocain  cannot  be  injected  before 
passing  even  the  small  probe,  the  attempt  will  be  rather  painful;  at 
the  second  attempt,  however,  one  can  usually  force  a  few  drops  of  a  3 
per  cent,  solution  through,  thus  making  the  treatment  less  painful. 
The  treatment  is  continued  until  the  cardinal  symptom  indicating 
stenosis,  persistent  weeping,  has  disappeared,  or  at  least  a  No.  5  probe 
passes  easily. 

Chronic  epiphora  does  not,  however,  always  mean  stenosis  of  the 
naso-lachrymal  duct,  nor  does  this  condition  always  rest  on  a  mechani- 
cal basis.  It  may  be  a  reflex  condition  as  the  result  of  diseases  of  the 
conjunctiva,  the  lachrymal  passages,  the  nose,  etc. ;  in  fact  it  may  also 
depend  upon  central  disturbances.  These  are  circumstances  which 
should  always  be  considered  in  the  treatment  of  the  affection. 

If  a  marked  blenorrhea  of  the  lachrymal  sac  exists,  the  examination, 
as  before,  is  preceded  by  testing  the  permeability  of  the  lachrymal 
passages.  In  nearly  all  the  cases  a  stenosis  will  be  found,  and  the 
treatment  as  above  described  must  be  instituted.  Conservative  meas- 
ures (passing  of  probes  and  lavage)  are  only  employed  in  those  cases  of 
blenorrhea,  which  are  not  yet  too  far  advanced.  If  the  walls  of  the 
sac  are  already  markedly  thickened,  if  the  sac  is  already  dilated  or 
perforated  after  acute  inflammation,  conservative  treatment  is  out  of 
the  question.  The  blenorrhea  itself  is  treated  with  a  ^  per  cent,  silver 
solution,  in  preference  to  all  other  agents. 

To  avoid  the  inconvenience  of  having  to  pass  Anel's  syringe  into  the 
canal  after  the  probe  has  been  taken  out,  the  operator  may  employ 
hollow  probes,  to  which  Anel's  syringe  can  be  fastened,  while  the 
probe  lies  in  the  naso-lachrymal  duct.  When  such  a  probe  is  pulled 
out,  the  solution  washes  the  duct  most  thoroughly.  A  fistula  in  the 
tissues  about  the  sac  forms  a  rare  indication  for  the  lavage  of  the  sac. 
To  determine  whether  the  fistula  is  connected  with  the  sac,  a  blue 


THE  LACHRYMAL  APPARATUS.  31 

douche  solution  should  be  used.  If  a  tumor  exists  in  this  region,  it 
may  be  necessary  to  pass  probes  to  determine  whether  or  not  the  sac 
is  free. 

Contraindications. — Probes  must  not  be  passed  in  acute  inflamma- 
tory conditions.  If  the  lachrymal-sac  disease  is  associated  with  disease 
of  the  bone  (tuberculosis),  the  passage  of  probes  is  contraindicated;  in 
such  cases  extirpation  of  the  diseased  sac  must  be  performed.  As  al- 
ready mentioned,  total  stenosis  of  the  naso-lachrymal  duct  is  also  an 
indication  for  extirpation  of  the  sac. 


CHAPTER  IV. 
TRICHIASIS. 

Of  the  numerous  operations  employed  for  the  relief  of  trichiasis, 
two  typical  methods  will  suffice  in  the  greater  number  of  cases,  viz.: 
those  of  Anagnostakis  and  of  Panas. 

The  Hotz-Anagnostakis  method  is  preferable  in  the  ordinary 
cases  of  trachoma.  It  gives  the  best  cosmetic  results.  The  skin  is 
incised  along  the  entire  length  of  the  lid,  either  with  a  scalpel  or  a 


FIG.  13. — Excision  of  the  fibres  of  the  orbicularis  muscle  (m)  covering  the  tarsus  (ta). 
With  forceps  the  fibres  are  grasped  along  their  upper  margin  at  the  left  angle  of  the  incision ; 
a  small  pair  of  curved  scissors  is  applied  close  to  the  tarsus,  and  with  short  cuts  the  muscle 
is  separated  along  the  entire  length  of  the  lid. 

lancet,  2  mm.  above  and  parallel  to  the  free  margin.  As  with  every 
incision  into  the  lid,  an  ivory  plate  is  placed  beneath  it,  not  only  to  pro- 
tect the  eyeball  but  also  to  provide  a  firm  base,  and  by  the  compression 
exerted  to  assist  in  checking  hemorrhage.  Lying  exposed  in  the  wound 
are  to  be  seen  the  reddish  fibers  of  the  orbicularis  muscle,  which  run 
parallel  to  the  edge  of  the  lid.  After  the  skin  has  been  freed  down- 
ward for  a  short  distance,  and  upward  to  the  upper  border  of  the  tarsus, 

32 


TRICHIASIS.  33 

the  fibers  of  the  muscle  are  excised  in  a  breadth  of  about  4  mm.  For 
this  purpose  they  are  lifted  up  with  a  tissue-forceps  at  one  end  of  the 
lid  (Fig.  13),  and  severed  all  the  way  to  the  other  end  of  the  lid  with 
one  stroke  of  the  scissors,  applied  flat.  In  this  manner  the  entire 
tarsus  is  dissected  free. 

In  most  cases  of  trachoma,  the  tarsus  is  usually  several  millimeters 
thick,  is  of  very  firm  texture  and  curved  convexly  forward.  The 
beautiful  striations  produced  by  the  Meibomian  glands,  seen  in  the 
tarsus  of  the  cadaver,  are  not  shown  in  the  tarsus  of  a  trachomatous 


FIG.  14. — With  the  knife  applied  flat  against  the  convex  anterior  surface  of  the  thickened 
tarsus  (ta),  thin  slices  are  cut.  The  upper  border  of  the  tarsus  and  the  margin  of  the  lid 
are  not  disturbed. 

patient.  In  the  latter  the  glands  have  disappeared  for  the  rnost  part, 
only  some  indistinct  traces  of  them  remaining.  It  is  best  to  excise, 
or  rather  to  diminish  the  thickness  of  this  useless  scar-tissue,  which  is 
the  cause  of  the  distortion  of  the  lid.  For  this  purpose  a  sharp  scalpel 
is  entered  (Fig.  14)  somewhat  below  the  upper  margin  of  the  tarsus  and 
parallel  to  its  plane,  and  with  a  sawing  movement  downward  thin  slices 
are  cut  away.  In  a  normal  tarsus  of  the  cadaver,  this  procedure  can- 
not be  demonstrated,  as  any  attempt  in  this  direction  would  im- 
mediately perforate  the  tarsus.  On  the*  other  hand,  in  a  trachoma- 
tous patient  there  is  little  danger  of  cutting  through  the  thickened 


34  OPHTHA'LMIC    SURGERY. 

tarsus.  However,  this  perforation  should  be  avoided.  Only  the 
uppermost  part  of  the  tarsus  retains  its  original  thickness;  the  margin 
of  the  lid  also  is  left  intact. 

The  Insertion  of  the  Sutures. — The  purpose  of  the  sutures  is  to 
stretch  and  straighten  the  tarsus  which  has  been  bent  backward  by 
the  disease.  This  is  effected  by  fastening  the  lower  margin  of  the 
skin-wound  to  the  upper  border  of  the  tarsus.  Because  of  thediffer- 


7 


FIG.  15. — Two  sutures  are  applied.  They  pass  from  above  through  the  skin  (u);  then 
through  the  upper  border  of  the  tarsus  (ta),  in  which  they  are  firmly  fastened;  and  lastly 
through  the  lower  margin  of  the  skin  (1)  above  the  cilia.  Corresponding  to  the  convex 
form  of  the  upper  tarsal  border,  the  tarsal  point  of  insertion  of  the  outer  suture  is  nearer 
the  lower  margin  of  the  wound  than  that  of  the  inner  suture. 

ence  in  the  height  of  these  two  points,  union  is  possible  only  if  the 
lower  border  of  the  tarsus  bends  forward  on  itself  and  carries  the  cilia 
into  the  desired  position.  The  sutures  are  therefore  introduced  in  the 
following  manner  (Fig.  15): 

The  skin  is  first  transfixed  above  at  a  point  corresponding  to  the 
middle  of  the  lid,  and  is  then  retracted  somewhat  by  an  assistant,  so 
that  the  upper  border  of  the  tarsus  is  exposed.  Next,  the  needle  with 
the  suture  pierces  the  upper  border  of  the  tarsus.  We  penetrate  in  a 


TRICHIASIS. 


35 


horizontal  direction,  introducing  the  needle  from  the  wound-surface 
and  bringing  it  out  again  immediately.  In  this  manner  perforation  is 
prevented,  which  accident,  however,  is  harmless.  The  assistant 
now  permits  the  upper  margin  of  the  cutaneous  wound  to  return  to  its 
normal  position,  and  the  lower  border  of  the  skin-wound  is  pierced  at  a 
point  corresponding  to  the  upper  point  of  entrance.  One  suture  is 
inserted  in  exactly  the  same  manner  on  either  side  of  the  first,  making 
three  in  all.  Frequently  four  or  five  sutures  are  employed.  The 
central  suture  is  tied  first.  The  two  margins  of  the  skin-wound  are 
approximated  with  two  tissue-forceps  in  the  hands  of  the  assistant. 
As  the  suture  is  tightened,  the  tarsus  with  the  free  border  of  the  lid 
bends  forward  and  somewhat  upward  (Fig. 
1 6).  It  is  better  to  induce  slight  over-correc- 
tion at  first,  so  that  the  margin  of  the  lid  is  at 
a  slight  distance  from  the  eyeball.  The  re- 
maining sutures  are  tied  with  the  same  care, 
the  ends  being  cut  off  at  about  the  same  length 
as  in  other  skin-wounds. 

A  simple  dressing  is  then  applied  and  kept 
from  adhering  by  the  insertion  of  gutta- 
percha  tissue  covered  with  ointment.  The 
other  eye  need  not  be  bandaged.  The  dress- 


-  ta 


ta 


FIG.  1 6. — Sagittal  section 
through  the  upper  lid  after 
completion  of  the  operation. 
The  margin  of  the  lid,  now 
placed  vertically  to  the  plane 

mg,  as  in  every  other  lid-operation,  should  be    Of  the  lid,  is  so  adjusted  to 

The  sutures 


the  tarsus  (ta)  that  no  part  of 
it  projects  into  the  palpebral 
fissure ;  in  fact,  only  a  small 
portion  of  the  wound-surface 
(the  cut  edge  (c)  of  the" 


changed  on  the  following  day. 
should  be  removed  after  four  days. 

Complications,  etc. — If  performed  in  the 

manner   indicated   the   operation  gives  good    tarsus)  remains  exposed, 
results.     As  the  edge  of  the  lid  is  not  injured, 

its  normal  outlines  are  preserved,  which  from  a  cosmetic  standpoint 
is  of  great  importance.  The  main  advantages  of  the  operation  are 
that  the  pathologically  heavy  tarsus  is  rendered  light  by  the  excision, 
and  the  lid  returns  to  its  normal  position  without  becoming  shortened 
in  the  slightest.  There  are  several  disadvantages.  The  tarsus  is 
crescentic  in  shape,  being  broadest  in  the  middle  of  the  lid  and  taper- 
ing off  somewhat  toward  both  angles.  Therefore,  the  effect  of  the 
()])(.•  ration  is  better  in  the  middle  of  the  lid  than  at  the  ends.  As  it  is 
not  necessary  to  turn  up  the  ends  so  far  in  order  to  attach  the  cutaneous 
wound-margin  to  the  upper  border  of  the  tarsus,  it  is  possible  in  certain 
rare  cases  that  the  trichiasis  at  the  margin  of  the  lid  is  not  completely 


36  OPHTHALMIC    SURGERY. 

overcome.  However,  by  excising  a  small  piece  of  skin,  the  lid  can  be 
slightly  shortened  and  raised.  At  the  same  time  a  small  incision  may 
be  made  into  the  intermarginal  border  at  a  corresponding  point,  so 
that  the  sutures  raise  the  cutaneous  layer  of  the  lid  with  its  cilia,  away 
from  the  eyeball.  The  small  wound  produced  in  the  intermarginal 
border  is  allowed  to  undergo  cicatrization. 

Beyond  this  provisional  incision  no  cut  is  made  into  the  inter- 
marginal border;  in  fact,  a  primary  intermarginal  incision  would  make 
the  stretching  of  the  tarsus  impossible,  for  as  soon  as  the  anterior 
cutaneous  layer  of  the  lid  is  separated  from  the  tarsus  by  such  an 
incision,  the  rolling  forward  of  the  lower  tarsal  border  can  no  longer 
be  accomplished  by  the  suture.  Correction  of  the  position  of  the 
tarsus  is  not  intended  in  the  secondary  provisional  intermarginal 
incision,  but  rather  a  displacement  of  the  layer  of  skin  containing  the 
hair-roots,  similar  to  that  in  v.  Jaesche's  operation.  This  latter 
operation  alone  would  allow  the  thickened  and  heavy  tarsus  to  retain 
its  curvature  toward  the  cornea,  keeping  up  the  irritation  as  before. 
Again,  it  must  be  remembered  that  the  wound  produced  in  the  inter- 
marginal border  must  heal  gradually  by  cicatrization,  which  would 
interfere  with  the  best  cosmetic  results.  The  lower  suture  must  not  be 
carried  through  the  intermarginal  border.  It  should  be  kept  in  front 
of  the  eyelashes;  otherwise,  it  will  eventually  cut  through  the  skin,  and, 
by  injuring  the  hair-roots,  cause  the  cilia  to  fall  out  and  possibly  give 
rise  to  an  ugly  indentation  in  the  edge  of  the  lid. 

The  possibility  of  recurrence  following  this  operation  need  not  be 
feared,  if  the  tarsus  has  been  treated  as  above  described.  The  thinning 
of  the  tarsus  is  an  essential  advantage,  resembling  in  this  respect, 
Snellen's  method.  If  the  tarsus  is  permitted  to  remain  intact,  the 
suture  may  be  inadequate  to  straighten  the  rigid  tarsus,  and  the  slight 
resultant  improvement  may  be  destroyed  by  subsequent  progressive 
contraction  of  the  scar  tissue. 

Panas's  method  is  a  much  more  radical  and  serious  operation, 
The  eyeball  is  protected  by  an  ivory  plate  and  the  incision  through 
the  skin  of  the  upper  lid  is  made  as  in  the  former  operation.  The 
muscle  bundle  of  the  orbicularis,  however,  is  divided  with  the  same 
stroke.  The  tarsus  is  freed  as  far  as  its  upper  margin.  Excision  of 
the  muscle-bundles  is  not  necessary  in  this  operation.  With  a  sharp 
scalpel  a  cut  is  now  made  through  the  tarsus  immediately  above  and 
parallel  to  the  margin  of  the  lid,  dividing  the  conjunctiva  and  extending 


TRICHIASIS.  37 

along  the  entire  length  of  the  lid.  Thereby  the  free  lid-margin  is 
converted  into  a  movable  flap,  which  is  connected  with  the  surrounding 
tissues  only  at  both  lid-angles.  This  flap  must  be  fastened  to  the 
exposed  tarsus  in  such  a  manner  that  union  is  effected  in  a  position 
with  the  eyelashes  directed  forward.  To  accomplish  this,  four  sutures 
are  inserted.  The  sutures  are  doubly  armed  and  the  needles  should 
be  thin  and  decidedly  curved.  First,  we  pierce  with  the  one  needle 
the  upper  margin  of  the  wound  in  the  tarsus  close  to  the  cut.  It  must  be 
held  parallel  to  the  wound-margin,  and  is  passed  from  the  anterior 
surface  and  brought  out  again  close  to  this  point.  Perforation  of  the 


FIG.  17. — After  cutting  through  the  skin  (s)  and  muscle  (m),  the  tarsus  (ta)  and  con- 
junctiva are  incised,  over  an  ivory  plate  placed  between  lid  and  bulb,  along  the  entire 
length  of  the  lid.  The  central  suture  has  already  been  introduced.  Above  it  is  fastened 
to  the  tarsus  near  the  edge  of  the  tarsal  wound.  Both  ends  of  the  suture  pass  downward 
between  tarsus  and  muscle  and  emerge  in  the  intermarginal  border  behind  the  cilia.  Over 
one  end  of  the  suture  a  glass  bead  is  drawn. 

thickened  tarsus  is  easily  avoided.  Should  it  occur,  it  is  of  little  im- 
portance, as  the  suture  is  drawn  into  the  conjunctiva  without  injuring 
the  cornea.  In  this  manner  the  suture  is  fixed  to  the  upper  part  of  the 
tarsus,  and  both  ends  pass  between  the  muscle  and  tarsus  of  the  free 
flap  through  the  intermarginal  border.  The  other  sutures  are  intro- 
duced in  a  similar  manner  (Fig.  17). 

The  assistant  now  turns  the  edge  of  the  lid  forward  with  forceps, 
thus  bringing  it  perpendicular  to  the  plane  of  the  tarsus,  and  the 
operator  ties  the  central  suture,  drawing  a  glass  bead  over  it.  He 
should  be  careful  not  to  tie  the  suture  so  tightly  that  the  glass  bead  will 


38  OPHTHALMIC    SURGERY. 

exert  pressure  on  the  edge  of  the  lid,  as  this  might  lead  to  circumscribed 
necrosis  and  subsequent  loss  of  eyelashes.  It  suffices  to  tighten  the 
knot  just  sufficiently  to  allow  firm  attachment  of  the  flap.  The  other 
sutures  are  treated  in  exactly  the  same  manner.  The  ends  of  the 
sutures  are  cut  off  short.  The  cutaneous  wound  must  then  be  closed 
with  several  sutures,  and  an  ointment-dressing  applied  to  the  operated 
eye.  The  sutures  may  be  removed  as  early  as  the  fourth  to  fifth  day. 

If  the  sutures  are  not  firmly  attached  to  the  upper  part  of  the  tarsus, 
the  operation  will  result  in  an  unsightly  disfigurement;  if  fastened  at 
too  high  a  point,  the  free  edge  of  the  lid  is  pulled  up  above  the  margin 
of  the  tarsal  wound,  and  the  tarsus  projects  free  into  the  palpebral 
fissure.  The  wound-surface  must  then  heal  by  granulation,  which 
requires  a  long  time,  and  terminates  finally  in  the  formation  of  a  scar. 
As  this  rough  cicatrix  is  directed  toward  the  cornea,  owing  to  the 
pathological  curve  of  the  tarsus,  irritation  of  the  cornea  follows.  If 
the  sutures  have  been  properly  inserted,  the  flap  fits  in  accurately 
and  without  any  disfigurement.  The  possibility  of  recurrence  is 
absolutely  excluded  by  this  method  of  operation. 

There  are  several  disadvantages  which  must  not  be  under-rated. 
The  base,  from  which  the  flap  derives  its  nourishment,  is  small  in 
proportion  to  the  length  of  the  flap,  and  is,  therefore,  in  danger  of  under- 
going necrosis.  Should  this  unpleasant  complication  arise,  the  patient 
has  not  only  been  disfigured  by  the  operation,  but  is  probably  even 
in  worse  condition  than  before,  as  now  the  upper  lid  is  shorter  by  the 
necrosed  piece,  and  a  resultant  lagophthalmos  may  be  produced.  Even 
if  the  operation  passes  off  without  complication,  the  upper  lid  has  been 
shortened  by  the  width  of  the  flap,  inasmuch  as  the  flap  has  been 
turned  out  of  the  plane  of  the  lid  to  one  perpendicular  to  it.  Short 
lids  in  patients  seeking  surgical  aid  must,  therefore,  be  considered 
another  contraindication,  to  the  operation,  as  in  such  cases  lagophthal- 
mos may  be  produced. 

The  lower  lid  may  be  operated  on  after  the  methods  of  Hotz  and 
Panas  in  exactly  the  same  manner  as  the  upper  lid.  Because  of  the 
small  size  of  the  tarsus,  however,  Hotz's  operation  is  less  favored. 

Other  methods  of  Operation. — With  the  foregoing  two  operations 
all  cases  of  total  trichiasis,  that  is,  in  which  the  disease  extends  along 
the  entire  length  of  the  lid,  and  which  still  have  their  cilia  arranged  in 
regular  order,  can  be  successfully  overcome.  The  method  of  Flarer, 
resection  of  the  layer  containing  the  hair-roots,  is  not  described  because 


TRICHIASIS. 


39 


it  is  always  disfiguring.  The  method  of  Jaesche-Arlt  consists  in  a 
displacement  upward  of  the  hair-root  layer.  Like  all  skin-transplan- 
tations on  the  lid-margin,  it  sets  up  fresh  irritation  of  the  cornea 
because  of  the  fine  lanugo  hairs,  always  present  in  the  skin. 


FIG.  1 8. — Position  of  the  intermarginal  and  skin-incisions,     (a).  Base  of  the  skin-flap 
containing  the  eyelashes,     (b).  Base  of  the  upper  skin-flap. 

Special  consideration  must  be  made  of  cases  in  which  the  trichiasis 
is  confined  to  only  one  end  of  the  lid,  and  also  of  those  in  which  the 
cilia  are  no  longer  arranged  in  a  regular  row,  but  stand  out  from  the 
lid-margin  in  various  directions,  occasionally  projecting  obliquely 
backward  from  the  posterior  edge  of  the  lid. 


IK;.  19. — The  flaps  interchanged. 

Partial  trichiasis,  at  either  end  of  the  lid  near  the  canthus,  is 
best  treated  by  the  operation  of  Spencer  Watson.  This  may  be 
briefly  described  as  follows  (Fig.  18  and  19):  An  incision  extending 
along  the  entire  length  of  the  area  affected  is  made  in  the  intermarginal 
border.  The  skin  of  the  lid  is  incised  2  mm.  distant  from  and  parallel 


40  OPHTHALMIC    SURGERY. 

to  the  margin  of  the  lid.  By  turning  downward  the  lid-margin,  the 
cutaneous  incision  is  made  to  terminate  at  the  canthus  and  join  the 
intermarginal  incision.  In  this  way  the  cilia  are  contained  in  a  flap, 
the  base  of  which  lies  on  the  side  away  from  the  canthus.  By  a 
second  skin-incision,  2  mm.  above  and  parallel  to  the  previous  one, 
another  flap  can  be  marked  out,  the  base  of  which  lies  on  the  side  of 
the  canthus.  By  undermining,  the  flaps  are  made  movable  so  as  to  be 
exchanged  in  such  a  way  that  the  flap  with  the  lashes  comes  above, 
while  the  upper  skin-flap  is  placed  at  the  margin  of  the  lid.  The 
flaps  are  held  in  the  new  positions  by  sutures  passing  through  their 
angles,  and  within  a  few  days  permanent  union  takes  place. 

If  this  method  were  applied  to  cases  extending  the  whole  length  of 
the  lid,  the  flaps  would  have  too  small  bases  as  compared  to  their  length, 
and  in  consequence  could  very  easily  break  down.  Like  all  skin- 
transplantations,  the  operation  has  the  drawback  of  inducing  renewed 
symptoms  of  irritation  from  the  fine  hairs  in  the  skin-flap.  However, 
as  the  flaps  in  the  cases  just  spoken  of  lie  to  one  side  of  the  cornea,  this 
is  not  a  very  important  disturbing  factor. 

When  the  regularity  of  the  arrangement  of  the  cilia  is  gone,  a 
condition  which  exists  in  the  more  severe  cases  of  trichiasis,  and  is 
often  associated  with  corneal  complications,  a  plastic  operation  must 
be  resorted  to.  This  is  performed  in  the  following  manner:  An 
incision  is  made  along  the  intermarginal  border,  and  the  skin,  together 
with  the  cilia,  is  dissected  away  from  the  tarsus  to  about  its  upper 
border.  As  the  skin  is  usually  rather  short,  there  is  some  retraction 
at  once.  By  means  of  a  few  fine  silk  sutures  the  skin-edge  is  attached 
to  the  tarsus,  a  few  mm.  above  the  margin  of  the  lid.  The  wound- 
surface  produced  in  this  manner  is  then  covered  with  a  flap  obtained 
from  the  mucous  membrane  of  the  lower  lip.  After  everting  and 
cocainizing  the  latter,  a  flap  of  the  size  and  shape  of  the  defect  in  the 
lid  is  marked  out  and  quickly  separated  from  the  underlying  structures. 
It  is  then  placed  upon  a  pad  saturated  with  warm  normal  salt  solution 
with  its  mucous  surface  downward,  and  a  pair  of  scissors  applied  flat 
to  the  surface,  is  used  to  free  it  of  all  adhering  shreds  of  fat,  so  that 
only  the  delicate  mucous  membrane  remains.  This  flap  is  then  placed 
upon  the  defect  in  the  lid  with  its  wound-surface  down,  and  its  edges 
are  brought  into  exact  coaptation.  Sutures  are  not  necessary  and  not 
even  to  be  recommended.  The  operated  eye  is  then  bandaged,  and 
a  piece  of  gutta-percha  tissue  covered  with  ointment  is  applied  over  the 


TRICHIASIS.  41 

upper  lid  to  prevent  the  dressing  from  sticking.  The  flap  soon  adheres 
and  heals  firmly  and  in  four  to  five  days  the  dressing  can  be  left  off. 

The  results  of  the  operation  as  regards  the  trichiasis  leave  nothing 
to  be  desired,  but  from  a  cosmetic  standpoint  the  operation  is  not 
a  success,  as  the  conspicuous  contrast  between  the  white  flap  and  the 
surrounding  skin  is  always  in  evidence.  In  these  severe  cases,  however, 
cosmetic  appearance  is  not  considered,  as  the  danger  of  grave  ocular 
complications  makes  reliable  operative  interference  absolutely  com- 
pulsory. Skin  from  the  arm  must  not  be  used  because  of  the  fore- 
going reasons.  We  have  repeatedly  been  compelled  to  excise  such  a 
transplanted  flap  from  individuals  in  whom  a  plastic  lid-operation  for 
trichiasis  had  been  performed  in  other  clinics,  because  the  fine  hairs 
of  the  flap  greatly  irritated  the  eye.  In  such  instances  the  skin-flap 
should  be  replaced  with  mucous  membrane.  The  patient  suffers 
more  from  the  fine  hairs  of  a  skin-flap  than  from  misdirected 
eyelashes;  the  latter  he  can  at  least  see  sufficiently  well  to  pull  out 
regularly  himself  with  forceps,  while  the  fine  hairs  of  the  skin  are 
almost  invisible. 

In  trichiasis  affecting  individual  lashes  the  best  mode  of  treat- 
ment is  electrolytic  epilation.  At  this  is  a  rather  painful  procedure 
the  lid  must  be  thoroughly  cocainized.  The  point  of  a  Pravaz  syringe 
is  inserted  into  the  skin  near  the  margin  of  the  lid  and  pushed  forward 
so  that  the  point  to  be  treated  becomes  completely  white  or  anemic 
during  the  injection  (infiltration-anesthesia).  The  epilating 
needle,  corresponding  to  the  negative  pole  of  the  battery  (the  other 
pole,  attached  to  a  moistened  flat  electrode  is  placed  over  the  forehead) 
is  then  inserted  close  to  the  cilia  and  pushed  into  the  sheath  of  the 
hair-bulb;  if  the  right  spot  is  chosen,  this  can  be  done  without  diffi- 
culty. If  a  current  from  one-half  to  one  milliampere  strong,  is  per- 
mitted to  act  for  30  seconds,  fine  vesicles  will  be  seen  to  rise  from  the 
hair-bulb,  and  the  hair  can  then  be  extracted  with  ease  by  the  use  of  the 
cilia-forceps.  It  is  of  advantage  to  employ  a  magnifying  lens  during 
the  introduction  of  the  needle,  so  the  exact  point  of  exit  of  the  hair 
may  be  more  readily  observed.  The  epilating  process  must  be  per- 
formed in  several  sittings,  as  occasionally  cilia,  which  have  not  been 
destroyed,  grow  again  and  cause  fresh  irritation. 


CHAPTER  V. 
ECTROPION. 

SPASTIC    ECTROPION. 

The  clinical  picture  of  spastic  ectropion  is  well-known,  as  the  con- 
dition is  frequently  seen,  especially  in  children  with  scrofulous  inflam- 
mation of  the  conjunctiva.  The  lid  appears  as  though  replaced  by  a 
tense,  red  mass — the  swollen,  edematous,  infiltrated  conjunctiva.  These 
cases  are  easily  relieved  by  Snellen's  suture  (Fig.  20).  The  thread 
used  has  to  be  double-armed  by  long,  flat,  strong  needles.  One 


FIG.  20. — At  the  highest  point  of  the  inverted  lid  lies  a  suture  3  mm.  long,  the  ends 
of  which  are  passed  under  the  skin  to  the  lower  border  of  the  orbit. 

needle  is  inserted  through  the  conjunctiva  at  the  junction  of  the  inner 
and  middle  third  of  the  highest  point  of  the  ectropion,  i.e.,  usually 
at  the  convex  cartilage  margin,  and  carried  under  the  skin  downward 
until  it  is  somewhat  below  the  lower  orbital  margin  where  it  is  passed 
out.  A  second  stitch  is  made  in  the  same  manner  with  the  other 
end  of  the  suture,  3  mm.  to  one  side  of  it.  By  this  procedure,  a  loop 

42 


ECTROPIOX.  43 

is  formed  which  overlies  the  palpebral  conjunctiva  in  the  place  where 
the  ectropion  is  most  prominent,  while  below  the  two  ends  of  the 
suture  hang  free  through  the  skin.  A  similar  loop  is  placed  at  the 
junction  of  the  middle  and  outer  thirds.  Both  ends  of  each  suture 
are  now  tied  over  a  small  pad  of  iodoform  gauze  and  tightened 
so  as  to  bring  the  lid  back  to  its  normal  position.  The  loops  exert 
their  action  on  the  highest  point  of  the  ected  afflid  (Fig.  21),  which 
is  drawn  down  and  brought  back  again  to  its  proper  position. 

The  same  suture  may  be  employed  in  the  treatment  of  spastic 


FIG.  21. — Vertical  section  through  the  inverted  lower  lid  with  the  suture  inserted.  The 
tarsus  has  been  bent  forward  during  the  closing  of  the  skin-wound.  The  eyelashes  are 
directed  forward  and  slightly  upward. 

ectropion  of  the  upper  lid,  the  threads  being  drawn  through  the  skin 
slightly  above  the  upper  orbital  margin. 

The  stitches  are  allowed  to  remain  in  position  for  at  least  three  or 
four  days,  but  may  be  left  longer  should  the  case  demand  it.  We 
must  wait,  however,  until  the  edematous  infiltration  of  the  conjunctiva 
has  disappeared,  as  the  swelling  tends  to  push  the  lid  away  from  the 
eyeball.  Spastic  ectropion  is  most  common  in  children  with  scrofulous 
conjunctival  inflammation  and  catarrhal  secretion,  in  whom  the 
employment  of  a  dressing  would  be  an  injury  rather  than  a  benefit. 
It  is  sufficient  to  cover  the  place,  at  which  the  knots  lie,  with  a  strip 
of  plaster,  leaving  the  eyeball  itself  free. 

SENILE  ECTROPION. 

An  entirely  different  method  of  operation  must  be  performed  in 
treating  senile  ectropion.  In  spastic  ectropion  an  otherwise  normal 
lid  is  brought  into  a  false  position  by  contraction  of  the  orbicularis 


44  OPHTHALMIC    SURGERY. 

muscle,  whereas  senile  ectropion  is  produced  through  marked  changes 
in  the  lid  itself,  which  have  originated  in  the  course  of  a  chronic  inflam- 
mation. The  lid  has  become  elongated,  the  tarsus  thickened  and 
heavier,  the  skin  flabby  and  not  capable  of  offering  resistance,  and  the 
lid,  therefore,  sunken  downward.  The  employment  of  Snellen's 
sutures  is  of  no  value.  Instead,  we  are  compelled  to  shorten  the  lid. 

The  simplest  method  of  operation,  and  in  fact  one  of  the  first 
methods  devised,  is  excision  of  a  triangular  piece  from  the  whole  thick- 
ness of  the  lid ;  the  base  of  this  triangle  corresponding  to  the  palpebral 
margin  and  of  such  length  that  the  lid,  after  union  of  the  wound  by 
several  silk  sutures,  is  of  the  desired  length,  and  lies  neatly  applied 
to  the  eye  in  its  normal  position.  This  simple  operation  had  one 
great  drawback;  namely,  a  coloboma  of  the  lid  was  frequently  pro- 
duced. The  tarsus  being  soft  and  easily  rent,  the  sutures  readily  cut 
through  it,  more  particularly  as  the  contraction  of  the  orbicularis 
muscle  constantly  exerts  traction  on  the  two  edges  of  the  wound. 
The  operation  has,  therefore,  long  since  fallen  into  disuse,  as  either  a 
large  coloboma  or  at  least  an  unsightly  indentation  of  the  lid-margin 
was  the  result. 

Kuhnt  tried  to  avoid  this  disadvantage  by  an  operation,  which  con- 
sists in  division  of  the  lid  at  the  intermarginal  border  and  subsequent 
shortening  by  cutting  out  a  triangular  piece  exclusively  from  the  tarsus. 
The  surplus  fold  of  skin  which  remains  as  an  ugly  prominence,  Muller 
attempts  to  remove  by  obliquely  suturing  it  to  the  tarsus. 

Another  method  is  to  shorten  the  lid  by  the  excision  of  a  piece  of 
skin,  which  is  taken  from  the  region  of  the  external  canthus;  in  this 
manner  an  attempt  is  made  to  draw  the  lid  outward  and  at  the  same 
time  to  elevate  it  somewhat.  The  procedure  has  the  disadvantage 
that  the  relaxed  skin  will  stretch  again  after  a  time,  often  allowing 
recurrence  of  the  ectropion. 

A  combination  of  the  methods  of  Kuhnt  and  Szymanowski,  i.e., 
of  the  tarsal  and  cutaneous  operation,  yields  perfect  results,  and  should 
be  employed  exclusively  for  the  treatment  of  senile  ectropion. 

The  First  Step. — The  operation  is  begun  by  splitting  the  lower 
lid  in  the  intermarginal  border.  This  procedure  is  not  easy  in 
patients  with  senile  ectropion,  as  the  intermarginal  border  is  usually 
indistinct,  the  posterior  border  of  the  lid  perfectly  rounded,  and  the 
conjunctiva  thickened.  It  is  desirable  to  make  the  incision  with  the 
lancet,  with  its  point  resting  on  the  intermarginal  border,  while  its 


ECTROPION.  45 

plane  lies  parallel  to  the  surface  of  the  lid.  By  so  doing,  we  avoid 
perforation  of  the  tarsus  or  wounding  of  the  skin  with  the  point  of 
the  lancet.  A  wound  of  the  tarsus,  when  it  lies  in  the  region  of  the 
piece  to  be  excised,  has  no  particular  significance;  but  if  it  lies  to  the 
side,  the  placing  of  the  sutures  in  the  tarsus  may  be  made  extremely 
difficult.  The  incision  in  the  intermarginal  border  usually  bleeds 
freely;  it  is,  therefore,  best  when  making  the  cut,  to  grasp  the  lid 
between  the  thumb  on  the  skin  side  and  index  finger  on  the  con- 


FIG.  22. — The  lid  is  fixed  between  the  thumb  and  index  finger  of  the  left  hand.  The 
lance  pressed  forward,  its  flat  surface  parallel  to  the  surface  of  the  lid,  in  the  intermarginal 
border,  at  first  to  the  center  of  the  lid.  The  incision  is  next  continued  outward  to  the 
external  canthus,  as  the  line  indicates. 

junctival  side  (Fig.  22).  The  lid  is  thereby  fixed  and  at  the 
same  time  rendered  comparatively  free  from  blood,  so  that  the  incision 
may  be  made  without  annoying  hemorrhage.  Satisfactory  anesthesia 
and  anemia  of  the  whole  field  may  be  produced  with  the  cocain  and 
adrenalin  mixture  described  in  an  earlier  chapter  (p.  15).  OIK 
has  to  inject  the  fluid  into  the  thickened  substance  of  the  tarsus  itself. 
Occasionally  the  solution  spurts  out  of  the  openings  of  the  Meibo- 
mian  glands.  A  Pravaz  syringe  (i  cc.)  is  amply  sufficient  for  this 
procedure. 


46  OPHTHALMIC    SURGERY. 

The  inter  marginal  incision  is  started  slightly  to  the  inner  side  of  the 
middle  of  the  lid  and  goes  exactly  to  the  external  canthus.  The 
greatest  precaution  must  be  observed  not  to  wound  the  skin,  as  this 
injury  may  produce  a  coloboma  of  the  lid.  In  order  to  prevent  falling 
out  of  the  eyelashes,  it  is  also  important  that  care  be  taken  not  to 
injure  their  roots.  When  the  point  of  the  lancet,  which  is  held  parallel 
to  the  lid-surface,  enters  the  intermarginal  border  between  the  two 
layers  of  the  lid,  it  sinks  without  much  resistance  between  them.  The 
lengthening  of  the  incision  to  the  external  canthus  by  pushing  the 
lancet  forward  laterally  is  not  to  be  recommended,  as  there  is  always 
a  risk  of  leaving  the  intermarginal  border  and  either  deviating  for- 
ward with  the  cutting  edge  of  the  knife  injuring  the  skin,  or,  backward, 
and  penetrating  the  tarsus.  It  is  decidedly  safer,  after  an  incision  has 
been  made,  corresponding  in  length  to  the  breadth  of  the  lancet,  to 
insert  the  point  of  the  lancet  in  another  place  on  the  intermarginal 
border  and  bury  it  in  the  tissue;  and,  when  necessary,  even  to  insert 
it  in  a  third  place.  Then  one  has  simply  to  unite  the  separate  incisions, 
if  they  have  not  already  been  connected  while  being  made,  by  cutting 
through  the  separating  fibers.  In  this  manner  the  lid  is  divided  with- 
out injuring  the  anterior  or  posterior  layers. 

If  the  operator  wants  to  perform  the  intermarginal  incision  in  one 
cut,  a  fine  line  must  first  be  cautiously  drawn  with  the  point  of  the 
lancet  and  gradually  deepened  by  making  short  cuts.  It  is  almost 
impossible  to  draw  this  line  if  the  intermarginal  border  cannot  be 
distinctly  seen,  as  is  the  case  when  the  whole  lid-margin  is  rounded 
by  the  ectropion.  Therefore,  we  must  be  satisfied  to  keep  behind 
the  lashes  near  the  posterior  margin  of  the  lid.  The  intermarginal 
incision  is  deepened  until  it  is  beneath  the  lower  margin  of  the  tarsus. 

The  Second  Step  is  the  Excision  of  a  Triangular  Piece  from 
the  Tarsus. — The  length  of  this  piece  depends  upon  the  degree  of  the 
ectropion.  If  too  little  is  excised,  the  ectropion  is  not  corrected ;  if  too 
much,  the  two  edges  of  the  tarsal  wound  cannot  be  re-united  by  sutures. 
The  operator  must,  therefore,  carefully  estimate  in  each  case  the  neces- 
sary length  of  the  area  of  excision.  This  is  best  done  by  raising  a 
fold  of  the  tarsus  with  two  pairs  of  forceps,  and  determining  exactly 
how  much  must  be  removed  to  allow  the  shortened  lid  to  lie  properly 
against  the  eyeball  (Fig.  23).  The  forceps  should  be  held  in  a  vertical 
position,  near  the  eye,  and  the  fold  (/)  allowed  to  protrude  forward. 
The  length  of  the  necessary  excision  may  be  only  5  mm.,  or  even 


ECTROPIOX. 


47 


double  or  more.  The  piece  of  the  tarsus  is  taken  exactly  from  the 
middle  of  the  lid  with  a  pair  of  short,  straight  scissors.  A  cut  is  first 
made  from  the  inner  corner  through  the  tarsus,  and  the  piece  limited 


FIG.  23. — Two  vertically-held  forceps  raise  a  fold  (f)  of  the  tarsus,  so  that  it  projects 
prominently  forward.  In  this  manner  we  determine  how  much  must  be  excised  from  the 
tarsus  so  that  it  can  subsequently  be  properly  attached  to  the  bulbus. 

by  cutting  from  the  other  side  obliquely  downward  from  the  edge  of 
the  lid  for  a  corresponding  distance.  The  excision  includes  only 
the  tarsus  and  the  overlying  conjunctiva.  The  conjunctiva  under 


FIG.  24. — The  measured  part  of  the  tarsus  has  been  excised.     The  triangle  is  drawn 
in  the  region  from  which  the  skin  is  to  be  excised. 

the  tarsus  must  not  be  touched  by  the  incision.  The  bleeding  is  con- 
trolled by  the  previous  injection  of  adrenalin,  but,  if  severe,  must  be 
checked  by  the  application,  for  a  short  time,  of  two  hemostatic  forceps. 


48  OPHTHALMIC    SURGERY. 

The  third  step  consists  in  the  excision  of  a  triangular  piece  of 
skin  from  the  region  of  the  external  canthus  (Fig.  24). 

The  first  incision  is  made  with  a  scalpel  or  lancet  from  the  canthus 
outward  and  is  carried  a  trifle  upward  (a  b}.  Its  length  equals,  or 
exceeds  somewhat,  that  of  the  piece  excised  from  the  tarsus. 

The  second  incision  is  carried  from  the  canthus  perpendicularly 
from  the  first,  i.e.,  downward  and  a  trifle  outward;  this  is  easily  twice 
as  long  as  the  first,  so  that  its  lower  point  lies  vertically  below  the  outer 


FIG.  25. — The  triangular  piece  of  skin  is  excised,  the  skin  of  the  lid  undermined  and 
turned  outward.  The  three  sutures  through  the  tarsus  lie  in  their  proper  position.  The 
principal  fixation  suture  of  the  flap  (a  b)  is  likewise  drawn  through.  The  cilia  are  excised 
from  the  corresponding  part. 


end  of  the  first  incision.  The  ends  of  these  two  incisions  are  united 
by  a  third,  and  the  piece  of  skin  so  isolated  is  excised.  The  skin  of  the 
lid  is  now  completely  undermined  so  that  it  may  readily  be  drawn 
outward  to  cover  the  defect  produced. 

The  fourth  step  consists  in  uniting  the  open  wounds  (Fig.  25). 
The  first  is  the  wround  in  the  tarsus.  Three  sutures  are  employed 
so  as  to  be  certain  of  the  permanent  union.  Strongly  curved,  fine 
needles  with  fine  silk  are  used.  The  needle  is  inserted  below,  near  the 


ECTROPION.  49 

point  of  the  triangle,  pushed  from  the  conjunctival  side  through  the 
tarsus  out  to  the  wound,  and  carried  on  the  opposite  edge  from  the 
wound  side  through  tarsus  and  conjunctiva.  The  needle  must  not  be 
passed  through  too  close  to  the  edge  of  the  wound,  because  the  tarsus, 
as  has  already  been  mentioned,  is  easily  torn,  and,  if  the  sutures  have 
once  cut  through,  a  second  fixation  is  still  more  difficult.  Both  ends 
of  this  suture  are  turned  upward.  The  second  suture  is  passed  through 
in  a  like  manner.  It  is  inserted  through  the  middle  of  the  tarsus,  both 
ends  should  be  placed  horizontally.  Special  care  must  be  employed 
to  properly  place  the  last  suture,  wrhich  insures  exact  union  of  the 
wound  and  must  re-establish  the  margin  of  the  lid.  To  accomplish 
this,  the  needles  have  to  be  put  through  the  tarsus  close  to  the  edge. 
The  threads  are  turned  downward. 

The  pair  of  sutures  turned  upward  are  tied  first.  Nothing  is  more 
unpleasant  for  the  operator  than  to  be  compelled  to  search  for  the 
threads  belonging  together  by  drawing  one  end  to  find  its  fellow;  for 
this  reason,  detail  description  of  the  arrangement  of  the  suture  ends  is 
dwelt  on.  As  soon  as  the  first  suture  is  tied,  and  the  edges  of  the  wound 
in  the  tarsus  approximated,  the  lid  begins  to  roll  inward  and  we 
must,  therefore,  in  order  not  to  work  against  this  movement  while 
tying  the  threads,  hold  them  perpendicularly  upward  and  avoid 
everything  which  might  contribute  to  the  separation  of  the  lid  from 
the  eyeball.  After  tying,  the  ends  of  the  suture  are  cut  off  close  to  the 
knot,  then  the  second  suture  is  tied  and  cut  off  close,  and  lastly  the 
third. 

On  the  cadaver  the  union  of  the  two  margins  of  the  wound  is  more 
difficult  than  on  the  living,  because  the  tarsus  presents  only  as  a  thin 
membrane.  In  living  patients,  the  wound-surfaces  lie  in  much 
better  apposition  in  consequence  of  the  thickened  tarsus  presenting 
a  broad  surface.  Usually  the  help  of  an  assistant  is  not  necessary  in 
bringing  the  margins  of  the  wound  together. 

If  the  two  portions  of  the  lid-margin  do  not  fit,  w'e  can  remove 
from  the  longer,  with  a  pair  of  scissors,  the  small  superficial  projecting 
wedge. 

The  last  step  is  the  covering  of  the  triangular  defect  in  the 
skin  by  means  of  skin  from  the  lid. 

From  that  part  of  the  skin  of  the  lower  lid  which  is  to  lie  beyond 
the  external  canthus,  we  excise  a  small  strip  in  order  to  remove  the 
eyelashes.  The  first  suture  fixes  the  apex  of  the  flap  (a)  (Fig.  26) 


^O  OPHTHALMIC    SURGERY. 

to  the  outer  angle  of  the  defect  (6);  the  suture  is  immediately  tied. 
As  in  every  skin -suture  accurate  approximation  of  the  edges  of  the 
wound  is  absolutely  necessary.  Next  follows  a  suture  (e)  along  the 
upper  margin  of  the  flap  and  the  skin  to  the  outer  side  of  the  upper 
lid;  in  addition  two  skin-sutures,  (c)  and  (d)  are  inserted.  A  suture 
between  the  tarsus  and  the  skin  of  the  lid-margin  must  be  made  if 
they  are  not  already  in  good  apposition.  It  occasionally  occurs  that 
a  gaping  fissure  is  found  between  them,  and  in  order  to  produce 
primary  union  (otherwise,  the  lid-margin  cannot  be  made  to  assume 
its  normal  appearance)  a  suture  is  placed  between  the  two  in  the 
following  manner :  both  needles  of  a  doubly-armed  suture  are  passed 


FIG.  26. — Appearance  after  the  operation.  The  lower  lid  lies  in  its  proper  position; 
4  (a,  b,  c,  d,  e)  sutures  sufficed  for  the  fixation  of  the  flap.  One  suture  for  the  fixation  of 
the  skin  to  the  tarsus  is  tied  over  a  bead  (f). 


from  the  conjunctival  side  out,  at  a  distance  of  i  mm.  from  the  margin 
of  the  lid  and  2  mm.  from  each  other,  through  the  tarsus  and  forward 
through  the  skin  and  tied  over  a  small  pad  of  gauze  or  a  bead.  An 
ordinary  suture  would  produce  an  unsightly  indentation  on  the  margin 
of  the  lid. 

The  lower  lid  is  now  shortened,  lies  closely  against  the  eyeball 
and  is  at  the  same  time  slightly  elevated. 

Great  care  must  be  taken  in  applying  the  dressing.  In  order  that 
no  space  exists  between  the  flap  and  the  underlying  structures,  it  must 
be  held  down  by  a  slight  pressure-bandage.  It  is  of  the  utmost  im- 
portance that  both  eyes  should  be  bandaged  for  four  days.  If  the 
eyes  are  allowed  to  move,  the  knots  in  the  tarsus  greatly  endanger  the 


ECTROPION.  51 

cornea  by  the  constantly  rubbing  against  this  sensitive  structure.  If 
both  eyes  are  closed,  the  cornea  rotates  upward  and  lies  behind  the 
upper  lid  and  is  not  in  contact  with  the  knots.  The  orbicularis  muscle 
is  kept  quiet  by  the  bilateral  dressing,  which  also  aids  in  the  prompt 
healing  of  the  wound.  After  the  operation,  a  small  amount  of  iodo- 
form  ointment  is  placed  in  the  conjunctival  sac.  The  bandage  should 
be  carefully  lifted  on  the  day  following  the  operation  to  see  that  the 
cornea  is  not  eroded.  After  four  days  the  sutures  may  be  removed 
from  the  tarsus,  and  a  day  later  from  the  skin.  Should  one  or  more 
of  the  sutures  in  the  tarsal  wound  tear  out  prematurely,  the  tear  must 
be  allowed  to  heal  by  granulation.  Beyond  delay  in  the  course  of 
healing,  this  occurrence  has  no  significance. 

As  already  mentioned,  the  result  of  the  operation  is  always  brilliant 
if  the  excised  piece  has  been  of  a  sufficient  size,  and  the  resultant  scar 
is  scarcely  visible.  The  existence  of  a  corneal  ulcer  does  not  centra- 
indicate  the  operation;  on  the  contrary,  it  can  readily  be  seen  how 
healing  of  such  an  ulcer  might  be  effected  without  any  further  treat- 
ment than  replacing  the  protecting  lid  in  its  proper  position. 

On  account  of  the  softness  of  the  tissues,  the  suture  in  the  tarsus 
may  cut  through  at  once,  especially  if  there  has  been  too  much  excision 
and  the  tissues  markedly  stretched.  For  this  reason,  as  has  already 
been  mentioned,  the  needle  must  not  be  passed  too  close  to  the  margin 
of  the  wound,  but  kept  away  sufficiently  to  allow  the  suture  to  have 
proper  support.  The  greatest  advantage  of  this  method  of  operation 
lies  in  the  fact  that  even  in  -the  cases  in  which  the  sutures  in  the  tarsus 
cut  through,  the  danger  of  a  coloboma  does  not  exist,  as  the  anterior 
plate  of  the  lid,  the  skin,  remains  uninjured.  For  this  reason  alone 
care  must  be  taken  not  to  injure  the  skin  in  making  the  intermarginal 
incision.  As  the  skin  itself  is  frequently  highly  friable  and  atrophic, 
the  skin-suture  may  also  cause  trouble. 

In  excising  the  triangular  skin-flap,  the  upper  incision  must  not  be 
carried  straight  upward,  as  Szymanowski,  for  other  reasons,  has 
advised,  but  only  with  a  slight  inclination  upward.  Otherwise,  the 
skin  of  the  lower  lid  will  be  drawn  too  far  over  the  tarsus,  and  the  union 
made  much  more  difficult.  If  the  pressure-dressing  is  properly  applied, 
any  stasis  of  secretion  is  prevented,  and  the  attendant  undesirable  con- 
sequence, such  as  rupture  of  the  skin-sutures  and  their  necessary 
removal,  is  avoided. 

I  have  recently  seen  a  rare  accident  occurring  after  an  ectropion 


52  OPHTHALMIC    SURGERY. 

operation.  The  lid  was  first  in  faultless  position,  and  I  was  not  a 
little  astonished  to  find,  the  day  afterward,  the  lower  lid  again  pre- 
senting a  marked  ectropion.  The  operation  appeared  to  have  been  a 
failure,  but  the  cause  of  the  new  ectropion  was  soon  recognized.  The 
skin  of  the  lower  lid,  which  had  been  stretched  outward,  exerted  its 
greatest  tension  in  the  region  of  the  lower  margin  of  the  tarsus;  this 
was  pressed  against  the  bulb  and  the  free  margin  of  the  lid  was  turned 
outward.  The  reposition  of  the  under  lid  into  its  proper  position  did 
not  improve  the  result,  and  only  after  applying  a  Snellen's  suture, 
full  recovery  followed. 

In  cases  of  bilateral  ectropion  both  eyes  should  be  operated  on  at 
the  same  time,  as  in  all  cases  both  eyes  must  be  bandaged  after  the 
operation;  this  spares  the  patient  the  prolonged  closure  of  the  eyes. 

If  the  ectropion  is  not  far  advanced,  the  ordinary  Kuhnt's  method  of 
operation,  with  possibly  Miiller's  modification,  will  be  sufficient.  In 
such  cases  the  intermarginal  incision  is  made  from  the  middle  outward 
toward  the  canthus;  the  corresponding  piece  is  excised  from  the  tarsus; 
the  tarsal  sutures  are  made  as  above  described;  and  the  skin  is  attached 
to  the  tarsus  by  several  sutures,  which  should  be  inserted  obliquely, 
to  avoid  the  formation  of  one  large  fold  of  skin;  instead  the  super- 
fluous skin  is  divided  into  several  small  folds,  which  later  become 
entirely  invisible. 

PARALYTIC  ECTROPION. 

For  correction  of  this  deformity,  resort  must  be  had  to  the  operation 
of  tarsorrhaphy,  which  is  described  on  page  65. 

CICATRICIAL  ECTROPION. 

As  a  typical  method  for  cicatricial  ectropion  does  not  exist,  the 
delineation  of  the  operative  procedure  is  incomparably  more  difficult 
than  those  from  the  other  forms  of  ectropion,  and  a  detailed  descrip- 
tion is  essential. 

In  general,  the  following  stages  may  be  considered  as  necessary: 
The  first  step  is  to  divide  the  cicatrix  which  is  holding  the  lid  in  an 
abnormal  position.  An  incision  is  made  with  a  scalpel,  parallel  to  and 
usually  quite  close  to  the  margin  of  the  lid,  throughout  the  whole  length 
and  depth  of  the  scar,  so  that  the  lid,  entirely  free  and  movable,  can 
be  brought  back  to  its  normal  position.  As  the  cicatrix  often  extends 
to  the  bone,  after  caries  and  deeply  penetrating  corrosions,  the  orbital 


ECTROPION.  53 

margin,  covered  only  with  periosteum  and  cicatricial  tissue,  can  become 
exposed. 

The  next  step  is  to  fix  the  lid  in  its  proper  position,  and  to  cover 
the  extensive  area  caused  by  the  drawing  away  of  the  lid.  This  is 
manifestly  the  most  important  part  of  the  operation,  as  otherwise, 
during  the  healing  of  the  wound,  the  new  cicatrix  would  draw  the 
lid  back  again  to  its  former  position.  This  may  be  remedied  by 
undermining  and  directly  approximating  its  margins,  or  by  a  plastic 
operation. 

The  defect  can  be  closed  by  sutures  only  if  the  wound  is  relatively 
small  and  the  surrounding  skin  in  a  normal  condition;  for  instance, 
if  an  ectropion  has  been  produced  on  the  external  portion  of  the  upper 
lid  by  a  small  scar  following  caries,  and  the  lid-margin  appears  to  be 
fixed  to  the  bony  orbital  margin.  After  thorough  separation  of  the 
scar  and  reposition  of  the  lid  in  its  normal  position,  the  approximately 
horizontal  wound  may  be  converted  into  a  vertical  one  by  sufficiently 
undermining  the  surrounding  skin  and  making  traction  on  the  middle 
of  the  upper  and  lower  edges  of  the  incision  with  two  blunt  hooks. 
Then  by  horizontal  sutures  the  incision  may  be  drawn  into  a  vertical 
line. 

By  approximation  in  a  slanting  direction,  that  is,  vertical  to  the 
earlier  direction  of  contraction  of  the  scar,  the  upper  lid  is  placed 
correspondingly  deeper,  and  in  slight  cases  actually  remains  per- 
manently in  its  normal  position.  Such  approximation  is  only  possible 
when  the  scar  is  small,  so  that  the  incision  can  be  a  short  one,  and 
when  the  surrounding  skin  is  in  a  normal  state.  But  it  is  impracticable 
in  such  conditions  as  the  cicatricial  changes  following  corrosives  or 
lupus,  which  have  so  affected  the  skin  as  to  make  it  unyielding. 

It  is  manifestly  wrong  to  do  the  operation  before  the  caries  had  been 
cured.  If  a  discharging  fistula  exists,  the  diseased  bone  has  to  be 
laid  bare  first  through  an  incision  and  curetted;  eventually,  the  seques- 
trum is  removed.  To  protect  the  cornea  from  the  danger  of  a  subsequent 
ectropion,  a  tarsorrhaphy  is  made.  In  this  operation,  by  fixation  of 
the  upper  lid  to  the  lower,  the  eversion  of  the  upper  lid  is  prevented. 
Then  the  diseased  process  is  allowed  to  run  its  course  and,  not  until 
it  has  completely  healed,  is  the  operation  of  dividing  the  scar  and 
obliquely  suturing  the  wound  performed. 

The  cases  in  which  suturing  suffices  for  the  repair  are  quite  few; 
usually  one  has  to  cover  the  defect  after  separation  of  the  cicatri* 


54  OPHTHALMIC    SURGERY. 

with  a  skin-flap  by  a  plastic  operation.  In  opposition  to  many  opera- 
tors we  believe  that  it  is  better  to  use,  whenever  possible,  flaps  with- 
out pedicles.  Leaving  out  of  the  question  the  fact  that  in  the  greater 
number  of  cases  of  cicatricial  ectropion  (corrosion,  lupus),  pedun- 
culated  flaps  from  the  surrounding  skin  cannot  be  taken  (the  skin 
itself  being  also  contracted  by  the  cicatrix),  the  cosmetic  effect  especi- 
ally leads  us  to  employ  for  covering  the  defect  delicate  flaps  without 
pedicles.  Pedunculated  flaps  project  from  the  surrounding  skin  as 
thick  irregular  elevations  and  produce  a  marked  disfigurement,  whereas 
the  extremely  thin  non-pedunculated  flaps  apply  themselves  smoothly 
against  the  denuded  tissue  and  after  some  time  present  the  same  folds  as 
the  healthy  lid  and  are  differentiated  from  their  surroundings  only 
by  their  somewhat  lighter  color.  The  claim  that  non-pedunculated 
flaps  constantly  contract  so  much  as  to  destroy  completely  the  results 
of  the  operation  is  not  true.  We  have  formed  new  upper  and  lower 
lids  by  means  of  non-pedunculated  flaps,  and  they  are  still,  after  some 
years,  in  a  faultless  position.  The  employment  of  the  surrounding 
skin  was  absolutely  impossible  in  consequence  of  a  marked  cicatricial 
contraction  following  corrosion  with  vitriol. 

The  results  'depend  entirely  on  the  manner  of  procedure  in  trans- 
planting these  flaps.  The  first  condition  necessary  is  a  marked  over- 
correction  of  the  defect.  In  the  severe  cases,  which  is  the  only  type 
considered  here,  the  whole  upper  and  lower  lids  are  found  turned  out- 
ward and  usually  lying  in  the  region  of  the  orbital  margin,  the  upper 
lid  closely  adherent  to  the  eyebrow.  Occasionally  the  margin  of  the 
lid  is  relatively  well  preserved.  The  first  step  in  the  operation  con- 
sists (as  already  stated)  in  the  division  of  the  scar  and  the  releasing 
of  the  lid;  an  incision  is,  therefore,  made  with  a  scalpel,  along  the 
whole  length  of  the  scar,  i.e.,  of  the  lids.  On  the  upper  lid  it  is  often 
difficult  to  keep  within  the  narrow  zone  between  the  eyebrow  and 
margin  of  the  lid;  so  far  up  has  the  lid  been  drawn  from  its  normal 
position.  If  no  lid-margin  is  present,  the  incision  is  made,  if  possible, 
at  a  distance  of  2  mm.  from  the  margin  of  the  conjunctiva.  After 
the  scar  is  completely  divided  or,  if  the  condition  demands,  excised, 
the  lid,  which  is  now  freely  movable,  is  drawn  well  over  the  other  lid— 
the  upper  down  over  lower,  or  the  lower  well  up  over  the  upper. 
Three  strong  sutures  are  now  passed  through  the  margin  of  the  freed 
lid  and  are  fastened,  either  on  the  cheek  (if  the  upper  lid)  or  on  the 
forehead  (if  the  lower  lid);  both  suture-ends  must  be  passed  through 


ECTROPION.  55 

the  skin  and  tied  over  a  small  pad  of  iodoform  gauze;  if  this  is  done, 
the  defect  will  be  covered  by  a  flap,  which  considerably  exceeds  in 
size  the  dimensions  of  the  normal  lid  The  hemorrhage  may  be 
checked  either  by  compression  or  by  temporary  clamping  with  hemos- 
tatic  forceps.  The  latter  may  be  twisted  off  after  a  short  time.  Liga- 
ture with  catgut  is  only  necessary  for  the  larger  vessels.  The  small 
vessels  in  the  scars  soon  stop  bleeding  without  assistance.  The  wound, 
produced  in  this  manner,  has  naturally  an  irregular,  obtuse,  triangular 
appearance,  its  surface  showing  as  a  depression  below  the  orbital 
margin  and  toward  the  side  of  the  nose.  It  is  now  temporarily  covered 
with  a  tampon  saturated  with  warm  normal  salt-solution. 

The  skin-graft  flaps  are  prepared  from  the  inner  side  of  the  upper 
arm.  In  order  to  form  an  idea  of  the  size  and  shape  of  the  flap  to  be 
excised,  a  piece  of  gutta-percha  tissue,  corresponding  to  the  wound  in 
form  and  size,  is  employed.  This  is  laid  on  the  part  from  which  the 
skin  is  to  be  excised.  After  thorough  disinfection,  the  skin  of  the 
arm  is  well  stretched  in  an  oblique  direction  by  the  assistant.  As  the 
skin  retracts  considerably  in  an  oblique  direction  after  being  loosened, 
the  flaps  must  be  made  much  broader  in  this  direction  and  trifle 
longer  than  the  size  of  the  paper-pattern.  The  flap  should  not  be 
wholly  separated  at  once;  first,  an  incision  is  made  on  one  side  with 
lateral  prolongations  from  each  end  of  this  for  a  short  distance.  The 
flap  is  now  ready  to  be  dissected  with  the  lancet.  It  should  always 
be  the  aim  to  remove  only  the  superficial  epithelial  layers  and  those 
in  the  form  of  a  single  flap,  and  for  this,  the  lancet  (keratome)  serves 
better  than  any  other  knife.  If  the  surface  of  the  lancet  is  placed 
parallel  and  close  to  the  skin,  it  is  not  difficult  by  a  stroking  motion 
to  separate  the  superficial  epithelial  layers.  -This  work  always  pro- 
ceeds slowly,  and  requires  the  greatest  attention  on  the  part  of  the 
operator. 

When  a  small  strip  has  been  freed,  it  is  rolled  outward  with  a 
pledget,  from  which  the  salt-solution  has  been  well  squeezed  out,  so 
that  the  further  dissection  can  be  continued  at  the  adhering  point. 
The  flap  is  detached  in  such  thin  superficial  sections,  that  bleeding 
only  occurs  from  the  apices  of  the  cut  papillae,  and  appears  in  the  form 
of  small  dots.  Care  must  be  taken  not  to  buttonhole  the  skin,  as  the 
openings,  although  small  at  the  outset,  increase  in  size  by  retraction 
of  the  margin  of  the  sections,  and  are  undesirable  because  their  margins 
roll  up  and  later  make  the  proper  adaptation  of  the  flap  to  the  wound 


56  OPHTHALMIC    SURGERY. 

impossible.  On  the  other  hand,  by  rapid  and  careless  working  in 
preparing  the  Map,  one  can  cut  too  deep  and  the  sections  are  then 
thick  and  heavy  and  retract  too  much.  When  a  section  of  the  wished- 
for  size  has  been  prepared,  it  is  separated  from  the  point  at  which  it  is 
still  attached  to  the  skin,  and  is  covered  at  once  with  two  pledgets 
saturated  with  warm  salt-solution.  Before  transferring  the  flap,  the 
denuded  surface  of  the  wound  should  be  stroked  with  the  edge  of  the 
lancet  in  different  directions,  in  order  that  a  small  amount  of  blood 
and  serum  may  exude  to  ensure  rapid  adhesion  of  the  flap  to  the  wound. 
We  must  manifestly  guard  against  deep  incisions,  which  through 
more  extensive  bleeding,  will  lift  the  flap  off. 

Now  follows  the  most  delicate  part  of  the  operation,  namely:  The 
adaptation  of  the  flap  to  the  surface  of  the  wound.  The  flap, 
which  until  now  has  been  spread  out  on  the  pledget,  is  placed  with  its 
wound-surface  on  the  defect,  at  first  as  its  shape  and  form  seem  to 
indicate.  The  middle  of  the  flap  is  then  pressed  well  against  the  raw 
surface,  best  by  means  of  a  pair  of  closed  forceps,  and  the  pressure 
continued  until  it  conforms  to  the  surface  of  the  wound;  especial  care 
being  taken  not  to  allow  hollow  spaces  to  separate  the  various  pits  in 
the  wound  from  the  flap,  more  particularly  at  the  inner  angle.  After 
this  follows  the  exact  adaptation  of  the  margin  of  the  flap  to  the  margin 
of  the  wound.  To  properly  spread  out  the  flap,  as  its  margins  roll  up 
in  every  instance,  the  latter  must  be  drawn  out  with  Carlsbad  needles,* 
and  applied  to  the  margin  of  the  wound  so  that  not  even  the  slightest 
interstice  remains  between  the  two.  If  the  flap  is  somewhat  too  large 
and  the  margins  project  over  the  edges  of  the  wound,  it  must  be  reduced 
to  the  proper  length  with  a  pair  of  scissors.  This  adaptation  must, 
naturally,  be  made  along  the  whole  periphery  of  the  flap.  Sutures  are 
not  recommended.  After  completing  the  adaptation,  the  flap  and  its 
surroundings  are  covered  with  an  oiled  gutta-percha  paper  and  covered 
loosely,  but  carefully,  with  sufficient  dry  gauze  to  cause  slight  com- 
pression. The  gauze  is  held  in  position  by  two  broad  strips  of  adhesive 
plaster.  The  other  eye  is  also  included  in  the  bandaging,  in  order 
to  prevent  all  movements  of  the  lid.  An  outer  starch-bandage  makes 
the  dressing  stiff  within  a  short  time.  The  operation  is  performed 
under  general  anesthesia.  The  wound  on  the  arm  need  not  be  sutured; 
the  skin  regenerates  within  a  short  time  from  the  islands  of  epithelium 
remaining  between  the  papillae. 

*A  kind  of  long  hat  pin,  the  end  of  which  has  the  form  of  a  small  lancet. 


ECTROPION.  57 

On  the  second  day  after  the  operation  the  dressing  is  changed  for 
the  first  time.  It  is  always  encouraging,  when  the  bandage  is  taken 
off,  to  find  the  flap  in  the  desired  position  and  already  adherent.  As 
no  wound-surface  exists,  there  is  naturally  not  the  slightest  secretion. 
The  flap  is  usually  quite  white,  but  occasionally  the  upper  epithelial 
layers  are  somewhat  darker  in  color.  Simply  because  of  this,  no 
necrosis  of  the  flap  need  be  feared.  Within  a  few  days  the  delicate 
normal  young  skin  makes  its  appearance  beneath.  Two  days  later, 
the  bandage  is  again  renewed.  The  fixation-sutures  have  by  this 
time  usually  cut  through,  and  are  now  removed.  The  lid  remains 
at  first  still  in  the  same  position,  and  the  flap  has,  by  this  time,  healed 
sufficiently,  to  prevent  its  being  displaced  during  a  change  in  the 
position  of  the  lid.  Gradually  and  slowly  the  lid  returns  to  its  normal 
position.  As  has  already  been  stated,  if  the  proper  precaution  and 
care  have  been  taken,  the  terminal  results  in  most  cases  will  be  excellent. 
The  skin  is  gradually  thrown  into  folds  as  is  the  normal  skin  of  the 
lid,  and  is  differentiated  from  its  surroundings  only  by  its  paler  color. 

Should  an  ectropion  exist  on  both  lids,  the  upper  lid  should  be 
operated  on  first,  and  some  weeks  later  the  lower  lid  may  be  corrected. 
If  the  flap  does  not  become  adherent,  it  is  found  to  be  of  a  greenish- 
black  color  at  the  first  change  of  dressings,  and  separated  by  profuse 
secretion  from  the  granulations  underlying  the  wound.  Nothing 
remains  to  be  done  in  these  cases  but  to  wait  until  the  cicatricial 
process  is  concluded;  then  the  original  condition  returns,  and  the  same 
operation  may  again  be  tried.  But  if  the  first  operation  is  com- 
pleted without  error  in  technic,  this  undesirable  occurrence  will 
be  met  with  only  exceptionally. 

The  plastic  operation  with  pedicled  flaps  is  described  else- 
where, (p.  115). 


CHAPTER  VI. 
ENTROPION. 

SPASTIC  ENTROPION. 

Gaillard's  Suture. — Spastic  entropion  can  readily  be  remedied  by 
Gaillard's  suture.  It  acts  in  a  manner  similar  to  Snellen's  suture 
(Fig.  27).  A  long  needle  curved  on  the  flat  is  introduced  under  the 
skin  at  the  highest  point  of  the  inverted  lid  and  carried  downward  to 
the  lower  border  of  the  orbit,  and  the  same  process  is  repeated  with 


FIG.  27. — Position  of  the  sutures.  A  suture  3  mm.  long  overlying  the  conjunctiva 
corresponding  to  the  most  marked  anterior  curvature.  Under  the  skin  the  sutures  extend 
to  the  region  of  the  lower  orbital  margin. 

the  other  end  of  the  suture.  Both  ends  of  the  suture  are  then  tied 
over  a  small  gauze  compress.  It  is  evident  (Fig.  28)  that  by  this 
suture  the  highest  part  of  the  inverted  lid  is  drawn  downward,  a  fold 
of  the  skin  of  the  lower  lid  is  tied  off,  and  the  edge  of  the  lid  is  thereby 
everted  from  its  position  and  turned  away  from  the  eyeball.  Two 
sutures  in  all  are  introduced,  one  at  the  junction  of  the  inner  and 

58 


ENTROPION.  59 

middle  thirds,  the  other  at  the  junction  of  the  middle  and  outer  thirds 
of  the  lid.  The  sutures  are  allowed  to  remain  four  or  five  days. 
The  sutures  are  then  removed  by  cutting  them  over  the  gauze  com- 
press, close  to  one  of  the  points  of  entrance  into  the  skin,  and  then 
drawing  them  through  the  wound.  Occasionally  a  spastic  entropion 
is  produced  under  the  bandage  after  cataract-operation.  To  restore 
the  lid  to  its  correct  position,  an  attempt  should  first  be  made  by  means 
of  a  strip  of  plaster.  Adhesive  plaster  is  to  be  avoided,  as  it  frequently 
produces  an  eczema.  Zinc  oxide  plaster  is  much  better,  but  often 
does  not  stick  well  in  this  position,  as  the  skin  is  moistened  by  over- 
flowing tears.  In  applying  this  plaster  it  is,  therefore,  important  to 
dry  the  lid  thoroughly  first;  then  the  strips  of 
plaster,  i  cm.  wide,  are  slightly  warmed  and  ap- 
plied, by  pressure,  at  one  end  accurately  to  the  edge 
of  the  lid.  The  other  end  of  the  strip,  which 
should  be  about  2  cm.  long,  is  drawn  downward, 
pulling  the  eyelid  with  it  into  proper  position  and 
fastened  firmly.  Disappearance  of  the  entropion  everted  lower  lid  with 

„       "  ,  .,        .,     ,  .        .  the  sutures  in  position. 

may  be  effected  more  easily,  if  the  patient  s  eye 
is  left  open  without  a  bandage.  For  protection  against  mechanical 
injury,  a  Fuchs'  lattice-frame  should  be  applied,  the  wire-netting 
being  covered  with  black  cloth.  The  bandage  may  with  safety  be 
left  off  as  early  as  the  day  after  the  operation,  provided  the  wound  is 
closed,  so  that  there  is  no  danger  of  the  upper  lid  springing  it  open 
during  the  action  of  the  palpebral  reflex. 

For  senile  entropion  of  the  lower  lid  the  best  method  consists  in 
excising  horizontally  an  oval  piece  of  the  skin  from  the  lid.  By 
picking  up  a  fold  of  skin  with  the  fingers,  an  approximation  can  first 
be  made  of  the  amount  of  excision  necessary  to  bring  the  lid  into  the 
proper  position.  It  is  easy,  then,  with  a  scalpel  or  lancet  to  cut  out  on 
a  plate,  placed  between  bulb  and  lid  a  corresponding  piece  of  skin 
of  oval  form  which  should  be  about  f  cm.  wide  at  its  middle  diameter. 
The  wound,  the  upper  edge  of  which  should  correspond  with  the 
border  of  the  lid,  is  then  closed  by  several  vertical  sutures.  The 
resulting  scar  is  hardly  visible. 

Graefe's  operation  consists  in  the  excision  of  a  triangular  piece 
from  the  skin  of  the  lower  lid  (Fig.  29).  The  first  incision  runs 
parallel  to  the  edge  of  the  lid  at  a  distance  of  3  mm.,  and  is  3  cm.  long. 
From  both  ends  (be)  of  the  middle  third  of  this  cut,  the  two  other 


60  OPHTHALMIC    SURGERY. 

incisions  (be  and  ce)  are  made  downward,  which  uniting,  form  with 
be  an  equilateral  triangle.  The  area  of  skin  thus  circumscribed  is 
excised.  The  edges  of  the  wound  at  b  and  c  are  slightly  undermined. 
The  first  suture,  which  is  now  introduced,  approximates  the  two 
lateral  angles  (be)  of  the  wound.  The  skin  is,  therefore,  shortened  and 
stretched  horizontally,  exactly  at  the  lower  border  of  the  tarsus; 
for  by  this  means  the  cartilage  is  pressed  toward  the  eyeball,  while 
the  free  border  of  the  lid  is  simultaneously  rotated  anteriorly  away 
from  the  globe.  The  rest  of  the  wound  is  closed  by  two  additional 
horizontal  sutures. 

Immediately  after  the  operation  the  lid  is  in  a  state  of  marked  ectro- 


FIG.  29. — Horizontal  incision  (ad)  through  the  skin  3  cm.  long,  parallel  to  and  3  mm. 
from  the  edge  of  the  lid.  From  the  middle  centimeter  (b  c)  two  incisions  (b  e  and 
c  e),  converging  below.  The  circumscribed  section  of  skin  is  excised.  Suture  of  the 
two  lateral  sides  (b  e  c)  of  the  lateral  triangle. 

pion,  and  to  such  an  extent,  indeed,  that  its  middle  portion  forms  a 
protuberance.  But  this  ugly  position  of  the  lid  disappears  within  a 
few  days,  during  which  the  skin  relaxes  a  little,  and  the  lid  slips  back 
into  its  normal  position.  If  the  first  suture  is  too  near  the  edge  of  the 
lid,  the  stretched  skin  presses  the  free  border  of  the  lid  backward 
against  the  eyeball  and  thus  increases  the  entropion.  If  the  suture 
is  too  low,  below  the  tarsus,  it  naturally  has  little  of  no  influence  on 
the  position  of  the  lid.  It  is,  therefore,  necessary  to  pay  special  attention 
to  the  first  incision,  parallel  to  the  edge  of  the  lid,  so  that  it  corresponds 
approximately  with  the  lower  border  of  the  tarsus;  i.e.,  3  mm.  from 
the  edge  of  the  lid.  Occasionally  after  the  operation,  the  lid  has  a 
tendency  to  slip  back  from  the  position  of  ectropion  into  that  of  entro- 


ENTROPION. 


6l 


pion;  this  may  be  prevented  by  means  of  a  small  gauze-compress, 
which  should  be  applied  along  the  lower  border  of  the  tarsus,  in  order 
to  press  it  backward  against  the  eyeball.  In  three  or  four  days  the 
sutures  may  be  removed. 

CANTHOPLASTY. 

The  purpose  of  canthoplasty  is  to  lengthen  the  palpebral  fissure. 

The  operation  is  performed  by  thrusting  the  blunt  end  of  a  moderate- 
sized,  straight  pair  of  scissors  horizontally  outward  into  the  con- 
junctival  sac  beneath  the  canthus,  which  is  then  cut  in  a  horizontal 
direction  with  one  stroke  of  the  scissors  (Fig.  30).  At  the  same  time 
the  other  hand  stretches  the  skin  in  the  region  of  the  canthus  by 


FIG.  30. — By  means  of  two  fingers  the  external  canthus  is  separated  and  at  the  same 
time  pushed  slightly  toward  the  nose.  A  pair  of  straight  scissors  is  introduced  horizontally 
with  the  blunt  blade  posterior. 

means  of  the  thumb  and  forefinger  which  are  placed  upon  the  outward 
halves  of  the  upper  and  lower  lids,  separating  them  and  drawing  them 
toward  the  nose  at  the  same  time.  If  the  cut  of  the  scissors  is  to  be 
made  on  the  left  eye  with  the  right  hand  of  the  operator,  the  hand 
must  be  strongly  flexed  dorsally,  in  order  to  bring  the  scissors  into  the 
right  position,  or  the  operation  must  be  performed  from  behind  the 
patient.  Bleeding  is  stopped  by  compression.  In  order  to  obtain 
a  satisfactory  result,  an  additional  cut  should  be  made  with  a  small 
pair  of  scissors  into  the  connective-tissue  strands,  which  attach  both 
lids  to  the  edge  of  the  orbit,  so  that  the  lids  are  freely  movable  and 
may  readily  be  separated  from  each  other. 


62  OPHTHALMIC    SURGERY. 

If  only  a  temporary  widening  (canthotomy)  of  the  palpebral  fissure 
is  desired,  no  further  operation  is  necessary.  The  wound  closes  in  a 
short  time,  without  leaving  a  permanent  increase  of  the  width  of  the 
palpebral  fissure.  Only  the  external  horizontal  scar  remains  as  a 
visible  sign  of  the  operation. 

In  order  to  obtain  a  permanent  result  (canthoplasty),it  is  neces- 
sary to  introduce  sutures,  which  close  the  wound  by  uniting  the  con- 
junctiva with  the  skin.  After  making  the  incision,  a  rhomboidal 
wound  is  seen  by  drawing  the  lids  apart  (Fig.  31).  If  the  con- 
junctiva be  undermined  a  little,  it  can  readily  be  drawn  outward  so 


FIG.  31. — Form  of  the  wound  after  incision.  Position  of  the  sutures  for  closure  of  the 
\vound.  The  first  suture  unites  the  angle  of  the  conjunctiva  (a)  with  the  angle  of  the 
cutaneous  wound  (b). 

that  the  angle  of  the  conjunctival  wound  (a)  may  be  connected  with 
the  angle  of  the  cutaneous  wound  (b).  All  that  is  then  necessary  is 
to  introduce  one  suture  above  and  below,  to  unite  the  lateral  sides  of  the 
conjunctival  and  cutaneous  wounds.  To  produce  anesthesia,  a  3  per 
cent,  cocain-solution  is  dropped  into  the  conjunctival  sac,  and  during 
the  second  part  of  the  operation  a  subcutaneous  injection  is  made  in 
the  neighborhood  of  the  external  canthus  with  a  half  syringeful  of  a 
i  per  cent,  cocain-solution. 

Indications. — Canthoplasty  is  indicated  if  there  is  a  marked  secre- 
tion of  the  conjunctiva  (blenorrhea,  trachoma,  etc.),  with  a  relatively 
narrow  palpebral  fissure,  making  it  difficult  to  carry  out  the  treatment 
and  to  promote  removal  of  the  secretion.  It  is  also  performed  in 
children  with  blepharospasm  and  edema  of  the  lids,  and  is  an  effectual 


ENTROPION.  63 

operation  for  spastic  entropion,  as  the  cut  of  the  scissors  includes  the 
point  of  insertion  of  the  orbicularis  muscle;  namely,  the  external 
canthal  ligament. 

Finally,  canthotomy  is  occasionally  necessary  to  permit  a  larger 
field  in  operations  on  the  eye  or  in  entering  the  orbit.  It  is  some- 
times indicated  in  iridectomy,  especially  in  pathologically  enlarged 
eyes  (buphthalmos) ;  and  in  the  operation  of  cataract  upon  patients 
whose  eyelids  twitch  considerably.  It  is  done  to  assist  in  performance 
of  exenteratio  orbits;  also  in  ankyloblepharon,  blepharophimosis,  etc. 


FIG.  32. — The  lidplate  is  inserted  outward  under  the  canthus.  The  direction  of  the 
incision,  to  be  made  later  through  the  canthus,  is  marked  on  the  patient  with  ink-dots  (i  i')- 
A  flap  of  skin  (f)  is  cut  out  of  the  lower  lid,  the  base  corresponding  to  the  outer  half  of  the 
marked  line. 

Kuhnt's  Method. — In  trachoma,  if  the  conjunctiva  is  markedly 
contracted  it  may  be  difficult  or  even  impossible  to  unite  the  con- 
junctiva with  the  skin.  The  sutures  tear  out  either  immediately  or 
shortly  afterward,  so  that  the  wound  closes  up  again  and  the  palpebral 
fissure  returns  to  its  former  small  size.  These  are  usually  urgent 
cases,  eyes  in  which  trachoma  has  caused  pronounced  infiltration  of 
the  cornea  that  has  resisted  all  treatment.  Such  cases  are  better 
for  Kuhnt's  modification  of  canthoplasty,  which  is  performed  as 
follows : 

By  means  of  a  few  India-ink  dots  the  line  of  incision  for  the  cantho- 
plasty is  first  drawn,  this  line  being  a  straight  prolongation  of  the 
palpebral  fissure  from  the  external  canthus  to  the  outer  border  of  the 
orbit.  A  Jaeger's  ivory  plate  is  then  inserted  under  the  outer  com- 
missure, and  while  stretching  the  skin  a  little  upward  and  toward 
the  temple,  the  operator  cuts  a  flap  of  skin  2  mm.  wide  out  of  the 


64  OPHTHALMIC    SURGERY. 

lower  lid,  as  indicated  in  Fig.  32.  The  base  of  the  flap  is  situated  so 
that  it  shall  be  adherent  to  the  upper  edge  of  the  wound  after  the 
incision  for  canthoplasty  is  made  (Fig.  33).  The  length  of  the  flap 
corresponds  approximately  to  one-third  the  length  of  the  lid,  but  must 
be  cut  a  little  longer,  as  the  skin  always  retracts  after  it  is  detached. 
The  orbicularis  fibers,  which  appear  in  the  lid  after  removal  of  the 
flap,  are  excised.  The  horizontal  external  incision  is  then  made 
as  in  ordinary  canthoplasty.  The  flap  of  skin  mentioned  above 
now  hangs  free  from  the  upper  edge  of  the  wound,  and  is  so  placed 
that  it  remains  several  millimeters  from  the  outer  angle  of  the  wound. 
By  means  of  a  scissors,  all  adhesions  of  the  lids  to  the  edge  of  the 


f 


FIG.  33. — The  flap  (f)  is  separated,  and  has  shortened  somewhat  by  contraction  of  the 
tissue.  The  incision  through  the  canthus  is  accomplished  so  that  the  same  wound- 
angles  in  the  skin  (b)  and  conjunctiva  (a)  are  produced  as  in  Fig.  31.  But  here  the  angle 
(a)  has  receded  towards  the  cornea,  as  a  result  of  retraction  of  the  contracted  conjunctiva. 

orbit,  have  to  be  thoroughly  cut,  so  that  the  lids  can  be  moved  freely, 
and  the  bulbar  conjunctiva  is  undermined  to  the  boundary  of  the 
cornea.  After  arrest  of  hemorrhage  the  wounds  are  closed  by  sutures. 
Three  sutures  are  sufficient  for  the  wound  on  the  lower  lid,  and  a 
fourth  fastens  the  temporal  border  of  the  lower  lid  obliquely  outward 
near  the  outer  angle  of  the  wound.  The  cutaneous  flap  itself  is  laid 
in  the  wound,  so  that  its  apex  is  inserted  either  under  the  angle  of  the 
conjunctival  wound,  or  is  fixed  to  the  latter  with  a  suture  (Fig.  34). 

As  there  is  usually  an  entropion  of  the  lower  lid  the  removal  of  a 
cutaneous  flap  also  exerts  a  favorable  influence  on  this  anomaly  of 
position.  If  the  upper  lid  should  need  correction,  the  flap  could 
be  taken  from  it  instead  of  the  lower  lid. 

In  severe  cases  of  trachoma  we  have  repeatedly  observed  a  very 


ENTROPION.  65 

favorable  influence  of  this  operation  upon  the  condition  and  further 
treatment  of  the  disease.  Certainly,  from  a  cosmetic  standpoint,  the 
operation  cannot  be  recommended,  but  in  such  severe  cases  the 
personal  appearance  no  longer  need  be  considered.  By  healing  of 
the  cutaneous  flap,  which  occurs  promptly,  the  palpebral  fissure 
remains  permanently  and  considerably  widened.  The  sutures  may  be 
removed  in  a  few  days. 

TARSORRHAPHY. 

The  object  of  tarsorrhaphy  is  to  shorten  the  palpebral  fissure. 
The  operation  is  necessary,  when,  as  a  result  of  lagophthalmos,  the 
eye  is  in  danger  of  being  injured.  It  is  indicated  in  cases  of  facial 


FIG.  34. — The  wound  on  the  lower  lid  is  sutured,  the  flap  of  skin  (f)  being 
fitted  into  the  angle  of  the  conjunctival  wound  (a). 

paralysis  that  will  presumably  exist  a  long  time  or  will  never  recover, 
and  in  cases  of  marked  exophthalmos  resulting  from  Basedow's  disease 
or  from  tumors.  Naturally,  the  cosmetic  result  is  never  pleasing, 
but  the  operation  is  rendered  necessary  by  existing  circumstances, 
and  is  unavoidable. 

The  method  of  Fuchs  is  almost  exclusively  employed  by  us.  The 
following  is  a  description  of  external  tarsorrhaphy:  At  the  outset 
it  must  be  clearly  determined  how  much  the  palpebral  fissure  it  to  be 
shortened.  This  is  best  done  by  holding  the  two  eyelids  together, 
with  the  fingers  placed  at  the  external  canthus,  and  shortening  the 
palpebral  fissure  by  advancing  the  fingers  until  the  patient  is  able, 
completely  or  almost  completely,  to  close  the  eye.  At  most,  a  few 
millimeters  will  be  sufficient,  but  even  in  severe  cases  a  distance  of  8mm. 
is  never  to  be  exceeded  on  account  of  the  marked  and  very  unsightly 


66  OPHTHALMIC    SURGERY. 

asymmetry  of  the  palpebral  fissure  that  would  thus  be  produced. 
In  such  a  case  we  would  be  forced  to  do  the  same  operation  also  at 
the  internal  canthus,  of  which  mention  will  be  made  later. 

At  the  desired  point  a  small  vertical  incision  is  made  through  the 
skin  of  the  upper  and  lower  lids,  not  only  to  indicate  how  far  the  opera- 
tion is  to  be  conducted,  but  also  to  secure  equal  distances  for  both 
lids.  A  subcutaneous  cocain-injection  is  made  in  the  upper  and  lower 
lids,  the  point  of  the  needle  being  directed  towards  the  intermarginal 
border,  in  order  to  make  the  incision  of  this  edge  painless. 

Then  an  intermarginal  incision  is  made  on  the  lower  lid,  beginning 
exactly  at  the  external  canthus,  and  extending  to  the  indicated  point. 


FIG.  35. — From  the  external  part  of  the  lower  lid  a  flap  of  skin  (f)  is  formed,  and  the 
cilia  removed.  From  the  skin  of  the  upper  lid  a  corresponding  long  strip  is  excised.  The 
suture  is  already  introduced :  above  near  the  edge  of  the  lid,  below  near  the  base  of  the  flap. 

The  eye  is  protected  by  the  ivory  plate.  The  incision  is  best  made 
with  a  lancet,  which  should  be  held  parallel  to  the  surface  of  the  lid, 
so  that  the  point  will  perforate  neither  the  skin  not  the  tarsus  posteri- 
orly. While  drawing  the  skin  of  the  eyelid  outward,  the  assistant 
presses  the  obliquely-held  ivory  plate  forward,  so  that  the  eyelid  is 
well  stretched.  By  light  pressure  the  operator  himself  holds  the  eyelid 
against  the  plate  and  places  the  point  of  the  lancet  upon  the  inter- 
marginal border.  If  the  lancet  is  sharp,  it  will  readily  penetrate 
between  the  two  plates  of  the  eyelid.  At  the  same  time  a  little  under- 
mining can  be  done. 

A  vertical  cutaneous  incision  3  mm.  long  is  then  made,  beginning 
at  the  point  marked  on  the  border  of  the  lid.  In  this  way  a  small 


ENTROPION.  67 

cutaneous  flap  (Fig.  35  /)  is  formed  from  the  lower  lid,  with  the  eye- 
lashes still  in  position  on  the  edge  corresponding  to  the  border  of  the 
lid.  The  roots  of  these  lashes  are  then  injured  by  means  of  a  scissors 
applied  flat  against  the  raw  side  of  the  flap  at  the  margin  of  the  lid, 
so  that  the  cilia  fall  out  later. 

The  Upper  Lid  is  Now  Prepared.  The  same  intermarginal  incision 
is  made  as  below,  from  the  external  canthus  to  the  mark.  Then  a 
cutaneous  incision  is  made  in  the  upper  lid,  parallel  to  its  border  at  a 
distance  of  about  2  mm.  from  it  and  of  the  same  length  as  the  inter- 
marginal  incision.  The  lancet  undermines  the  bridge  of  skin  thus 
formed,  and  two  cuts  with  the  scissors  sever  its  connections  externally 
and  internally.  In  this  way  a  raw  surface  is  produced  on  the  edge  of 


FIG.  36. — Appearance  of  the  palpebral  fissure  after  the  tying  of  the  sutures.     Both  ends 
of  the  first  suture  introduced  are  tied  over  a  small  gauze-compress. 


the  upper  lid.  The  flap  formed  from  the  lower  lid  is  now  adjusted 
so  that  it  covers  this  raw  surface  and  unites  with  it.  The  tarsi  are 
not  injured  in  this  operation.  The  tarsus  of  the  lower  lid  slips  in 
beneath  that  of  the  upper  lid. 

The  fixing  suture  is  made  with  a  double-armed  thread.  Both  needles 
are  first  passed  through  the  upper  lid  near  its  border,  proceeding  from 
the  conjunctival  surface  outward.  The  two  perforations  are  about 
2  mm.  apart.  A  short  piece  of  thread,  therefore,  lies  on  the  conjunct  ival 
surface  side  of  the  upper  lid.  This  is  of  no  consequence  as  it  does 
not  come  in  contact  with  the  cornea,  which  lies  farther  inward.  Then 
each  end  of  the  thread  is  passed  through  the  base  of  the  flap  on  the 
lower  lid  from  the  raw  surface  outward  to  the  cutaneous  side,  with 
about  the  same  distance  between  the  perforations  as  before  (Fig.  36). 


68  OPHTHALMIC    SURGERY. 

If  both  ends  of  the  thread  are  then  tied  over  a  small  compress  of 
iodoform  gauze,  the  base  of  the  flap  will  be  drawn  to  the  edge  of  the 
upper  lid,  and  the  flap  itself  will  lie  over  the  raw  surface  of  it.  Several 
fine  cutaneous  sutures  are  then  introduced  to  unite  accurately  the  edges 
of  the  flap  with  those  of  the  wound  on  the  upper  lid.  A  light  dressing 
is  applied  over  the  eye.  The  stitches  may  be  removed  on  the  third 
day.  As  the  interference  has  been  slight,  the  other  eye  need  not  be 
bandaged. 

The  advantage  of  the  operation  is  that  a  surface  union  of  the  lids 
is  produced,  and  in  this  way  a  separation  of  the  suture  is  avoided — an 
occurrence  which  is  often  encountered  in  other  methods  of  operation. 
The  disadvantage  of  this  method  lies  in  the  sacrifice  of  a  part  of  the 
normal  cutaneous  border  of  the  lids.  If  at  some  future  time  it  should 
be  desirable  to  re-open  the  palpebral  fissure,  it  is  not  difficult  to  free 
the  upper  and  lower  tarsal  borders,  as  the  tarsus  has  not  been  injured, 
and  a  few  sutures  will  unite  the  edge  of  the  cutaneous  wound  with 
this  edge  of  the  tarsus,  but  the  border  of  the  eyelid  thus  made  would 
naturally  have  no  cilia.  Therefore,  tarsorrhaphy  is  performed  only 
in  those  cases,  in  which  presumably  no  recovery  is  to  be  expected,  e.g., 
in  many  cases  of  facial  paralysis.  The  operation  may  be  accom- 
panied by  unpleasant  results,  caused  by  an  inequality  in  the  length 
of  the  intermarginal  incisions  on  the  upper  and  lower  lids.  If,  for 
example,  a  longer  piece  is  excised  from  the  upper  lid  than  will  be 
covered  by  the  flap  from  the  lower  lid,  the  latter  will,  of  necessity,  be 
pulled  obliquely  upward  and  inward,  producing  in  this  way  an  ugly 
fold  resembling  an  epicanthus.  At  the  same  time  the  cilia  on  the 
neighboring  part  of  the  lower  lid  may  also  assume  an  oblique  direction, 
and  in  this  way  a  trichiasis  will  be  produced.  Should  this  occur  it 
would  become  necessary  to  destroy  additional  eyelashes  by  electrolytic 
depilation. 

Indications. — Tarsorrhaphy  is  well  suited,  not  only  to  cases  of 
lagophthalmos  caused  by  facial  paralysis,  but  also  when  the  con- 
dition is  caused  by  congenital  shortening  of  the  eyelids;  further,  it  serves 
to  overcome  paralytic  ectropion,  as  it  raises  the  ptosed  eyelid.  It  is 
also  recommended  as  a  preventive  of  cicatricial  ectropion  in  persistent 
carious  fistula  on  the  border  of  the  orbit.  Even  though  the  operation 
in  itself  is  disfiguring,  it  may  still  be  indicated  for  cosmetic  reasons 
in  some  rare  cases,  such  as  widening  of  the  palpebral  fissure  after 
strabismus  operations,  or  unilateral  enlargement  of  the  eyeball  (uni- 


ENTROPION.  69 

lateral,  high  grade  myopia)  and  its  consequent  widening  of  the  palpebral 
fissure.  Tarsorrhaphy  is  also  performed  occasionally  as  a  preliminary 
to  plastic  operations. 

Complete  closure  of  the  palpebral  fissure  is  only  undertaken  in 
rare  cases.  For  example,  after  an  extensive  corrosion,  in  which  the 
skin  of  the  upper  and  lower  lid  has  been  partially  destroyed,  and  the 
production  of  a  cicatricial  ectropion  seems  unavoidable.  The  latter 
can  be  prevented  by  complete  suture  of  the  palpebral  fissure.  In 
order  not  to  destroy  all  the  eyelashes,  the  operation  may  be  performed 
by  denuding  with  the  lancet  the  edges  of  the  lids  behind  the  cilia  and 
then  suturing  the  lids  together:  Or,  if  it  is  possible,  a  narrow  strip 
may  be  cut  out  of  the  skin  of  both  eyelids  near  their  borders,  and  the 
two  raw  surfaces  united  by  sutures.  If,  however,  the  lid  has  been 
completely  destroyed,  and  the  eye  itself  has  not  suffered  much,  it  is 
best  to  protect  the  eye  by  a  moist  chamber  sufficiently  long  until 
cicatrization  has  ceased,  and  it  is  possible  to  perform  a  plastic  opera- 
tion, such  as  described  for  cicatricial  ectropion. 

If  tarsorrhaphy  is  performed  for  pronounced  exophthalmos,  after 
the  operation  is  completed,  the  rest  of  the  palpebral  fissure  should  be 
temporarily  closed  by  several  sutures  without  denudation  of  the  lid- 
margin,  in  order  that  the  flap  may  adhere  firmly,  and  the  sutures  not 
tear  out  prematurely,  owing  to  the  strong  tension. 

If  indicated  for  paralytic  ectropion,  a  triangular  fold  of  skin  may 
be  excised,  as  in  senile  ectropion,  and  the  tarsorrhaphy  combined  with 
this;  an  operation  resembling  the  Szymanowski  method.  In  this 
manner  the  somewhat  enlongated  lid  is  shortened  and  brought  to  lie 
more  closely  against  the  eyeball. 

Internal  Tarsorrhaphy. — When  Fuchs's  tarsorrhaphy  is  performed 
at  the  internal  angle  of  the  lids,  two  precautions  must  be  observed: 

(1)  The  internal  canthus  itself  should  not  be  touched  by  the  operation. 

(2)  The   lachrymal   canaliculi   must   not   be   \vounded.     The   inter- 
marginal  incision  is,  therefore,  made  from  the  point  (determined  as 
before)  to  the  end  of  the  tarsus,  i.e.,  to  the  punctum  lachrymale.     If 
the  incision  is  made  accurately  in  the  intermarginal  border  and  the 
lancet  penetrates  between  the  two  surfaces  of  the  lid,  there  is  no  danger 
of  wounding  the  lachrymal  canaliculus,  as  it  is  embedded  in  the  tarsus 
itself.     The  same  is  true  of  the  upper  lid.     In  other  respects  the 
operation  is  the  same  as  at  the  external  angle.      The  horseshoe-shaped 
excision  is  retained  and  appears  as  a  shallow  depression.     In  this 


70  OPHTHALMIC    SURGERY. 

way,  if  it  should  be  desired  to  re-open  the  palpebral  fissure  in  the 
future,  a  normally  formed  internal  palpebral  angle  can  be  obtained. 

In  marked  cases  of  exophthalmos  it  may  be  absolutely  necessary 
to  perform  the  operation  simultaneously  at  the  outer  and  inner 
angles  of  the  lids,  in  order  to  transform  the  palpebral  fissure  into  a 
short  central  aperture. 

Median  tarsorrhaphy  may  also  be  accomplished  (v.  Arlt)  by 
removing,  by  means  of  forceps  and  scissors,  a  strip  of  skin  from  the 


FIG.  37. — Horse  shoe-shaped  excision  along  the  inner  canthus 
from  the  skin  of  the  upper  and  lower  lids. 

upper  and  lower  lids  near  the  inner  angle,  in  such  a  manner  that  the 
wounds  thus  produced  meet  in  a  sharp  angle  at  the  internal  canthus 
of  the  eye  (Fig.  37).  Three  sutures  introduced  vertically  unite  the 
wounds  and  close  the  palpebral  fissure  from  its  inner  side.  This 
operating  has  the  advantage  of  not  injuring  the  cilia,  so  that  an 
eventual  re-opening  finds  the  edges  of  the  lids  intact. 


CHAPTER  VII. 

PTOSIS. 
HESS'S  OPERATION. 

After  previous  shaving  of  the  eyebrow  a  horizontal  incision  is 
made  through  the  skin  of  the  eyebrow  along  the  entire  length  of  the 
palpebral  fissure  to  avoid  disfigurement.  The  incision  should  be 
so  placed  that  the  short  scar  is  completely  covered  by  the  eyebrow. 
The  section  includes  only  the  skin,  as  a  deeper  incision  injures  large 
vessels,  bleeding  from  which  would  disturb  the  further  course  of  the 
operation.  After  the  incision  has  been  made,  the  skin  is  undermined 
downward  with  the  knife  beneath  the  convex  border  of  the  tarsus, 
i.e.,  to  a  point  near  the  edge  of  the  lid.  The  beginning  of  the  dis- 
section is  made  slightly  more  difficult  by  the  numerous  muscle- 
fibers  which  are  inserted  into  the  skin  at  this  point.  A  little  further 
down,  however,  the  subcutaneous  tissue  is  loose  and  easily  separated 
with  the  knife.  As  the  bleeding,  even  if  present  only  slightly,  inter- 
feres with  the  operation  by  collecting  in  the  pocket  constituting  the 
field  or  operation,  it  is  recommended  to  control  the  position  and  prog- 
ress of  the  knife  from  without,  through  the  skin.  This  may  be 
done  by  pushing  the  knife  downward  in  a  perpendicular  position, 
parallel  with  the  skin,  and  fixing  the  skin  at  as  low  a  point  as  possible 
(Fig.  38).  The  skin  is  thus  undermined  in  the  whole  length  of  the 
incision  with  a  few  strokes,  and  a  four-cornered  pocket  produced. 
In  this  way  we  can  more  readily  avoid  a  buttonholing  of  the  skin, 
than  if  we  try  to  operate  along  the  posterior  surface  of  the  skin  with 
an  insufficient  view  into  the  pocket,  a  procedure  that  is  difficult  with  a 
small  incision. 

After  the  undermining  is  completed,  the  insertion  of  the  sutures 
is  begun.  The  strong  silk  threads  are  doubly  armed  with  long,  flat 
needles.  In  all,  three  sutures  are  employed,  the  first  in  the  center  of 
the  lid,  the  two  others  to  the  sides.  Both  needles  of  the  first  thread 
are  pushed  through  the  lower  part  of  the  skin,  at  a  distance  of  approx- 
imately 4  to  8  mm.  from  the  edge  of  the  lid.  To  accomplish  this 
the  skin  must  be  fixed  with  the  forceps,  one  blade  of  which  remains 


72  OPHTHALMIC    SURGERY. 

in  the  pocket,  and  the  other  lies  on  the  skin  at  the  point  of  intended 
transfixion,  in  order  to  prevent  retraction  of  the  lax  skin  and  allow  of 
insertion  of  the  sutures  just  at  the  place  determined  on  (Fig.  39).  The 
needles  with  the  thread  are  now  brought  out  through  the  skin-wound 
and  directed  upward.  In  like  manner,  the  outer  and  the  inner  sutures 
are  inserted  each  about  one  centimeter  from  the  middle  stitch.  Both 
ends  of  the  middle  thread  are  then  pushed  upward  behind  the  upper 
edge  of  the  wound  near  the  periosteum,  therefore,  behind  the  muscle, 
and  are  brought  out  through  the  skin  close  to  one  another  at  about  a 


FIG.  38. — Hess's  operation  for  ptosis.  Method  of  undermining  the  flap.  The 
forceps  grasps  the  skin  at  as  low  a  point  as  the  progress  of  the  undermining  permits.  The 
knife  held  vertically  presses  downward  behind  the  skin  and  is  observed  by  the  operator 
from  the  front  through  the  skin,  (c),  Section  through  the  skin. 

distance  of  i-^  to  2  cm.  from  the  incision.  The  outer  threads  are 
treated  in  the  same  way.  The  ends  of  the  inner  thread  are  not  inserted 
directly  perpendicularly,  but  should  be  inclined  a  little  inward  toward 
the  median  line. 

The  three  threads  are  next  tied  over  iodoform  pads.  This  raises 
the  lid  and  at  the  same  time  forms  a  fold  in  the  skin  corresponding  to 
the  point  of  entrance  of  the  threads,  similar  to  the  normal  fold  of  the 
lid.  The  above  mentioned  distance,  as  the  insertion  of  the  thread, 
varying  from  4  to  8  mm.  must,  therefore,  be  adjusted  according  to  the 
position  of  the  fold  of  the  lid  on  the  other  side.  A  fold  lying  too  high 
is  just  as  disfiguring  as  one  too  near  the  edge  of  the  lid. 


PTOSIS. 


73 


Slight  traction  on  the  threads  raises  the  lids  so  that  the  palpebral 
fissure  readily  attains  its  normal  width,  but  in  tying  the  threads,  they 
must  be  drawn  up  sufficiently  to  lift  the  lid  higher  than  normally,  i.e., 
to  cause  an  over-correction.  However,  the  threads  should  not  be  drawn 
too  tightly,  as  this  will  make  them  cut  through  quickly,  without  materi- 
ally elevating  the  lid  more  than  with  threads  drawn  moderately  tight. 
The  skin-wound  is  closed  with  several  silk  sutures. 

The  Dressing. — Immediately  after  the  sutures  are  tied,  a  condition 


FIG.  39. — Application  of  the  sutures.  The  forceps,  one  blade  of  which  should  be  in 
front  of,  the  other  in  the  wound,  grasps  the  skin  just  where  the  needle  is  to  be  inserted. 
One  end  of  the  thread  has  already  been  drawn  through,  the  needle  mounted  on  the  other 
end  has  only  just  been  inserted. 


of  total  lagophthalmos  is  naturally  produced.  Because  of  this,  the 
eye  is  covered  with  a  celluloid  shield,  so  as  to  produce  a  comparatively 
air-tight  covering  (Fig.  40).  It  suffices  to  fasten  the  shield  along  its 
border  with  adhesive  strips,  and,  if  extensive  spaces  exist  between 
shield  and  underlying  parts,  they  should  be  filled  in  with  absorbent 
cotton.  Within  a  few  minutes  the  shield  becomes  moist,  and  under 
this  dressing  the  eye  may  remain  for  weeks  without  the  slightest  sign 
of  irritation.  As  the  celluloid  shield  is  sufficiently  transparent  to 


74  OPHTHALMIC    SURGERY. 

permit  a  view  of  the  eye,  the  dressing  is  changed  only  when  secretion 
is  present,  and  the  eye  must  be  cleansed. 

After-treatment. — The  sutures  closing  the  skin-wound  may  be 
removed  in  from  three  to  four  days,  but  the  sutures  retaining  the 
lid  in  its  elevated  position  should  remain  undisturbed  as  long  as  pos- 


FIG.  40. — After  treatment.  The  skin-wound  has  been  closed  by  several  sutures.  The 
three  fixation  threads,  of  which  the  inner  inclines  a  little  toward  the  median  line,  are  tied 
over  pads.  The  lid,  strongly  elevated,  stands  off  a  little  from  the  bulb,  the  new  fold  of  the 
lid  corresponding  to  the  puncture  points  of  the  threads.  For  the  protection  of  the  eye, 
which  cannot  now  be  covered  by  the  upper  lid,  a  celluloid  shield  is  employed;  it  is  fastened 
at  its  circumference  by  strips  of  zinc  oxide  plaster,  only  a  few  pieces  of  which  show. 


sible — at  the  least,  fourteen  days;  if  they  have  not  become  loosened  by 
this  time,  even  longer — three  weeks.  By  this  time  they  are  usually 
so  loose  as  to  have  lost  their  hold  and  may  be  easily  withdrawn  after 
being  cut  through.  The  object  of  leaving  the  stitches  so  long  is  the 
formation  of  strands  of  scar-tissue  along  the  threads,  which  not  only 
unite  the  lid  with  the  frontalis  muscle,  through  which  the  threads  have 


PTOSIS.  75 

been  brought,  but  also  serve  as  tendons  by  means  of  which  this  muscle 
elevates  the  lid. 

The  one  indication  for  the  operation  is  a  case  of  ptosis  in  which 
the  patient  absolutely  shows  distinct  contraction  of  the  frontalis  muscle. 
This  most  patients  with  ptosis  are  actually  able  to  accomplish.  The 
forehead  lies  in  constant  folds,  and  the  skin  of  the  eyebrow  is  con- 
stantly pulled  far  up  over  the  upper  border  of  the  orbit,  which  would 
correspond  to  its  normal  position.  In  those  who  make  no  attempt 
to  improve  their  ptosis  by  contraction  of  the  frontalis  muscle,  the 
operation  promises  very  little. 

If  the  threads  are  drawn  tightly  and  produce  an  over-correction  it  is 
not  necessary  to  form  a  loop  and  tighten  this  frequently  in  order  to 
maintain  the  lid  in  its  normal  position.  The  chances  and  results  of 
the  operation  are  always  improved  if  the  threads  are  pulled  tightly  at 
the  outset.  As  the  lid  is  not  shortened  by  excision,  but  only  by  the 
pushed-up  anterior  (skin)  flap  of  the  split  lid  which  unites  at  a  higher 
point  with  the  posterior  flap  and  raises  the  lid,  lagophthalmos  need  not 
to  be  feared.  Of  the  many  cases  of  Hess's  ptosis-operation  that  I 
have  performed  personally  or  have  seen  at  the  clinic,  this  result  has 
not  occurred.  This  is  certainly  a  strong  point  in  favor  of  this  method 
of  operation.  It  is,  however,  to  the  disadvantage  of  the  operation 
that  we  are  not  certain  at  the  beginning  of  the  terminal  results.  But 
this  is  not  possible  in  any  one  of  the  many  operations  for  ptosis  which 
have  been  recommended.  As  yet,  there  is  no  method  to  enable  us 
with  certainty  to  make  the  palpebral  fissure  of  the  affected  side  exactly 
the  same  width  as  that  of  its  normal  fellow. 

The  results  of  Hess's  ptosis-operation  are  in  the  great  majority 
of  cases  very  good;  occasionally  they  are  excellent,  and  but  rarely 
unsatisfactory.  Permanent  over-correction  need  never  be  feared. 
In  bilateral  ptosis  especially,  it  should  be  the  operation  of  choice. 
It  is  easy  of  performance  and  the  cosmetic  results  are  excellent.  The 
scar  at  the  point  of  incision  is  later  covered  by  the  eyebrow,  and  if  the 
sutures  are  properly  inserted,  a  good  position  of  the  fold  of  the  lid  is 
obtained. 

Anesthesia. — The  operation  may  be  most  satisfactorily  performed 
under  cocain-anesthesia.  Onesyringefulof  a  i  percent,  solution  (i  c.c.) 
suffices  as  injection  into  the  skin  of  the  eyebrow  and  lid.  Before  the 
threads  are  brought  out  at  the  upper  point,  a  second  syringeful  must 
be  injected  into  the  tissues  about  the  periosteum  of  this  region. 


70  OPHTHALMIC    SURGERY. 

Contraindications. — Apart  from  insufficient  contraction  of  the 
frontalis  muscle,  the  operation  is  contraindicated  in  those  cases  in 
which,  in  addition  to  the  ptosis,  there  is  paralysis  of  the  superior 
rectus  muscle  or,  as  in  some  cases,  a  total  ophthalmoplegia.  If  the 
eye,  during  sleep,  is  not  drawn  upward  under  the  conjunctiva  of  the 
upper  lid,  there  is  danger  of  resultant  disease  of  the  cornea.  This 
result  may  also  be  brought  about  by  the  occasional  swelling  of  the  skin 
of  the  upper  lid  after  the  operation,  through  an  effusion  or  other 
edema  projecting  downward  over  the  border  of  the  lid.  This  coming 
into  direct  contact  with  the  cornea  may  produce  erosions  and  ulcer- 
ations,  as  has  been  my  personal  experience  in  two  cases. 

In  this  as  in  every  other  operation  for  ptosis,  we  must  always  con- 
sider the  possible  occurrence  of  diplopia,  as  the  result  of  existing 
paralysis  of  the  ocular  muscles,  after  the  correction  of  the  ptosis.  This 
would  furnish  just  as  important  a  contraindication  to  the  operation  for 
ptosis,  as  an  abnormal  position  of  the  affected  eye,  for  example,  by  sec- 
ondary contractures  after  paralysis. 

PAGENSTECHER'S  SUTURES. 

The  stitches  in  Hess's  method  of  operation  are  essentially  the  same 
as  those  recommended  by  Pagenstecher.  The  great  efficacy  of  Hess's 
operation  is  due  to  the  change  in  position  of  the  anterior  layer  of  the 


FIG.  41. — Pagenstecher's  suture. 

lid  brought  about  by  the  sutures.  Pagenstecher's  sutures  should  be 
used  only  in  the  slightest  forms  of  ptosis.  As  the  stitches  are  allowed 
to  remain  in  place  for  a  long  time,  it  is  best  to  employ  a  wire  suture, 


PTOSIS.  77 

the  upper  end  of  which  is  shortened  by  twisting,  producing  a  sufficient 
elevation  of  the  lid.  In  order  to  avoid  scarification  of  the  skin,  the 
sutures  are  introduced  subcutaneously  (Fig.  41).  From  the  point  of 
entrance  at  the  one  end,  the  suture  is  carried  up  and  brought  out 
above  the  eyebrow  through  c.  The  other  end  of  the  suture  is  carried 
outward  subcutaneously  for  2  mm.  from  a,  and  then  withdrawn  at  b. 
The  needle  is  re-inserted  at  the  same  point  b  and  brought  out  above, 
either  at  c  or  at  d.  It  is  then  twisted  over  a  gauze  pad.  The  one 
suture  is  inserted  at  the  inner  third,  the  second  suture  at  the  outer 
third  of  the  lid. 

EVERBUSCH'S  OPERATION. 

Indication. — The  advancement  of  the  levator  palpebrae  is  an 
operation  intended  to  overcome  ptosis  brought  about  by  a  paresis  of 
this  muscle.  The  object  of  the  operation  is  to  make  the  weakened 
muscle  stronger  by  shortening  and  suturing  its  point  of  attachment 
further  forward.  The  first  part  of  the  procedure  is  to  lay  the  muscle 
bare.  This  is  not  so  easy  in  living  patients.  Anesthesia  is  pro- 
duced at  the  beginning  by  cocainizing  the  conjunctiva,  and  later  by 
injecting  i  cc.  of  a  i  per  cent,  cocain-solution  under  the  skin  and 
into  the  deeper  parts  of  the  lid. 

The  Dissection. — A  longitudinal  incision  through  the  skin  of  the 
lid  and  the  orbicularis  muscle,  is  made  midway  between  the  arch  of 
the  eyebrow  and  the  border  of  the  lid.  The  eye  is  protected  by  a 
horn-plate  placed  between  it  and  the  lid.  By  undermining  to  some 
extent  both  borders  of  the  lid- wound,  it  is  easy  to  expose  below  the 
upper  border  of  the  tarsus,  and  above,  the  thin  tarso-orbital  fascia. 
In  order  that  the  preparation  of  this  part  of  the  operation  may  be 
readily  understood,  it  is  well  to  briefly  recall  the  topographical  rela- 
tions in  this  region. 

If  a  sagittal  section  is  made  through  the  orbit  near  its  middle, 
the  appearances  seen  are  approximately  as  follows  (Fig.  42). 

The  border  of  the  orbit,  b;  attached  to  this  is  the  fascia  tarso- 
orbitalis  (/.  0.),  which  hangs  down  like  a  curtain  and  becomes  thickened 
below  at  the  tarsus  (to);  in  front  of  it,  the  fibers  of  the  orbicularis 
(m.o.)  and  the  skin  with  the  lashes  at  the  free  border  of  the  lid;  behind 
it  and  passing  forward  on  the  roof  of  the  orbit,  the  levator  palpebrae 
(m.l.),  which  spreads  out  at  the  orbital  opening  like  a  fan;  its  apo- 
neurosis  joins  the  fascia  tarso-orbitalis,  so  that  immediately  above  the 


78  OPHTHALMIC    SURGERY. 

upper  border  of  the  tarsus  no  more  than  a  membrane  is  visible — the 
tarso-orbital  fascia,  which  has  united  with  the  aponeurosis  of  the 
levator  palpebrte.  A  cut  through  the  fascia  at  this  point,  would  come 
directly  upon  the  conjunctival  fornix  (c)  and  would  not  touch  the 
muscle. 

If,  however,  the  cut  is  made  slightly  higher,  carefully  piercing  the 


&~\- 


—  r.s. 


II 


FIG.  42. — Sagittal  section  through  the  lids  and  the  anterior  portion  of  the  orbit, 
b.  Upper  border  of  the  orbit;  f.  o.,  The  tarso-orbital  fascia,  which  is  attached  to  the 
bone,  hangs  down  and  blends  with  the  tarsus  (ta.).  The  levator  muscle  (m.  1.)  passes 
forward  above  the  superior  rectus  (r.  s.),  changes  here  into  a  fan-like  tendon,  which, 
joined  by  the  tarso-orbital  fascia,  is  inserted  into  the  upper  part  of  the  tarsus.  Behind  the 
tarsus  is  seen  the  conjunctiva  (c),  in  front  of  it  the  orbicularis  muscle  (m.  o.).  1.  1.,  repre- 
sents the  transverse  section  through  the  lower  lid. 


fascia,  which  at  this  point  is  thin,  there  will  readily  be  seen  the  radiating 
red  bundles  of  the  muscle  which  may  be  traced  upward  into  its  com- 
pact body.  Therefore,  the  fascia  must  be  incised  at  from  5  to  6  mm. 
above  the  tarsus;  at  this  point  the  muscle-bundles  of  the  levator 
palpebrae  will  be  exposed  (Fig.  43). 

Three  sutures  must  now    be  inserted  through  the  muscle  in  the 
same  manner  in  which  they  were  inserted  in  the  advancement  of  the 


PTOSIS. 


79 


recti  muscle — first  through  the  middle.  With  a  fairly  strong  curved 
needle  the  middle  of  the  muscle  is  transfixed  in  its  entire  thickness, 
the  horn-plate  remaining  in  place,  at  as  high  a  point  as  possible;  the 
same  stitch  is  repeated  with  the  same  needle.  In  this  manner  a  loop 
is  produced  by  the  drawing  together  of  which  the  middle  fibers  of  the 
muscle  are  constricted.  A  second  loop  is  placed  to  its  inner  side 
(Fig.  44),  and  a  third  loop  to  its  outer,  both  at  the  same  height.  Now 
the  muscle  is  cut  through,  2  mm.  below  the  threads,  along  the  entire 


FIG.  43. — Everbusch's  operation  for  ptosis.  The  incision  made  midway  between 
eyebrow  and  border  of  the  lid  through  the  skin  (s)  and  orbicularis  muscle  (m.  o.)  is  held 
open  by  tenacula.  The  tarso-orbital  fascia  is  also  cut  near  the  upper  margin  of  the  wound 
(the  border  of  the  wound  (c)  is  visible  as  a  white  line)  and  turned  down  in  such  a  way  that 
the  transition  of  the  levator  palpebrae  muscle  into  its  tendon  is  plainly  visible  in  the  wound ; 
at  m,  it  blends  with  the  tarso-orbital  fascia. 

length  of  the  lid,  and  a  piece  excised  3  to  5  mm.  or  more  broad,  that  is, 
downward  to  the  upper  border  of  the  tarsus  or  even  including  a  small 
piece  of  the  tarsus  itself.  The  conjunctiva  as  far  as  it  comes  within 
the  reach  of  the  piece  to  be  excised,  need  not  be  saved,  but  may  be 
removed  with  the  muscle.  However,  with  slight  care,  it  is  not  difficult 
to  excise  the  piece  of  muscle  without  injuring  the  conjunctiva;  but 
when  a  strip  of  the  tarsus  is  included,  the  conjunctival  covering  cannot 
be  preserved,  as  it  is  too  intimately  adherent. 


8o 


OPHTHALMIC  SURGERY. 


The  gaping  wound  is  closed  either  by  bringing  all  six  ends  of  the 
threads  between  the  tarsus  and  the  orbicularis  muscle,  through  the 
intermarginal  space  and  tying  them  over  rubber  tubes;  or,  as  I  prefer, 
by  sewing  the  ends  of  the  catgut  threads  to  the  anterior  surface  of  the 
tarsus  so  that  the  upper  cut-edge  of  the  muscle  is  drawn  over  the  cut- 
edge  of  the  tarsus  to  its  anterior  surface,  to  which  it  heals  (Fig.  45). 

The  skin-wound  is  closed  over  these  sutures  with  several  stitches 
(Fig.  46).  This  method  of  operation  has  the  advantage  that  the  margin 
of  the  lid  is  in  no  way  disfigured.  If  the  threads  are  drawn  through 


FIG.  44. — The  middle  thread  has  already  been  inserted.  The  second  stitch  is  just 
being  inserted;  to  do  this  the  operator  lifts  the  lateral  part  of  the  muscle  with  forceps  in  the 
form  of  a  fold  and  pushes  the  needle  through  the  entire  thickness  of  the  tissue. 

the  intermarginal  space  and  tied  there,  the  underlying  materials, 
glass-beads,  gauze-pads  or  rubber-tubes,  almost  invariably  induce  a 
circumscribed  and  superficial  necrosis  of  the  margin  of  the  eyelid,  as 
the  stitches  must  remain  a  number  of  days.  The  lashes  fall  out  in 
the  necrotic  area,  and  occasionally  the  scarification  may  bring  about 
a  high  grade  deformity  of  the  lid-margin,  even  to  incurving  of  the 
lashes — trichiasis.  Because  of  this,  the  margin  of  the  lid  should,  if 
possible,  be  spared. 

The  result  of  the  operation  is  in  most  cases  good,  although  it  is 


PTOSIS. 


s, 


difficult,  and  even  impossible,  to  determine  exactly  just  how  much 
muscle  should  be  excised  to  attain  the  desired  result.  Caution  must 
be  exercised  during  the  operation  to  limit  the  excision  of  the  lid  suffi- 
ciently to  prevent  resultant  lagophthalmos.  On  this  account  the 
piece  to  be  incised  should  never  be  broader  than  5  mm. 

Contraindications. — This    operation    is,    however,    only    suitable 
when  the  levator  is  not  completely  paralyzed.     This  is  ascertained  by 


FIG.  45. — After  excising  a  strip  of  muscle  (and  conjunctiva)  5  mm.  broad,  the  middle 
pair  of  threads  is  first  fastened  on  to  the  anterior  surface  of  the  tarsus  (ta);  during  the  tying 
the  end  of  the  cut  muscle  is  pulled  onto  the  anterior  surface  of  the  tarsus  and  heals  thereon. 


asking  the  patient  to  close  both  eyes  as  in  sleep,  so  that  the  super- 
ciliary ridge  may  be  brought  in  its  normal  position  immediately  on 
the  upper  border  of  the  orbit.  The  skin  of  the  superciliary  region 
must  then  be  fixed  in  its  position  on  both  sides  by  firm  pressure  with 
the  thumbs.  If  now,  the  patient  at  command  can  open  the  eye 
even  though  only  to  a  limited  extent,  there  is  proof  of  some  action  of 
the  levator,  and  the  muscle  is  not  completely  paralyzed.  We  may 
then  expect  success  from  the  operation  of  Everbusch. 
6 


82 


OPHTHALMIC    SURGERY. 


SUMMARY. 


Hess's  operation  yields  good  results  only  when  the  patient  is  able 
to  raise  the  lid  through  contraction  of  the  frontalis  muscle  ;  otherwise, 
not  much  improvement  can  be  expected.  Occasionally  after  per- 
forming Hess's  operation,  it  is  noticed  that  the  patient,  having  the  same 
degree  of  ptosis  as  before,  lifts  the  operated  lid,  even  to  the  normal 
breadth  of  the  lid-fissure,  only  in  the  moment  when  the  sound  eye 
is  closed.  The  explanation  for  this  may  be  found  in  the  fact  that, 
not  until  the  sound  eye  is  closed,  can  the  patient  contract  his  frontalis 
in  order  to  elevate  his  palsied  lid.  When  contraction  of  the  frontalis 
on  the  operated  side,  while  the  sound  eye  remains  open,  does  not 


FIG.  46. — Appearance  of  the  lid  after  the  operation.     The  skin-wound  is  exactly  approx- 
imated by  several  sutures.     The  edge  of  the  lid  remains  perfectly  intact. 

seem  possible  to  the  patient,  it  is  not  attempted.  Likewise,  after  a 
Hess's  operation  has  been  performed  on  one  side,  the  patient  can  open 
this  eye  to  its  normal  width,  but  only  with  great  elevation  of  the  lid 
the  other  eye  through  excessive  simultaneous  contraction  of  the 
frontalis.  The  bilateral  innervation  of  the  frontalis  muscle  brings 
about  in  such  individuals  an  excessive  widening  of  the  palpebral 
fissure  on  the  sound  side,  while  effecting  only  the  normal  opening  on 
the  affected  side.  Only  in  bilateral  ptosis  can  we  expect,  with  cer- 
tainty, good  results  from  Hess's  operation;  and,  no  matter  what  oper- 
ation is  performed  it  is  impossible  in  unilateral  ptosis  to  restore  and 
maintain  the  palpebral  fissure  to  exactly  the  same  width  as  on  the 
normal  side.  In  any  case,  the  operation  should  be  performed  whenever 
possible  under  local  anesthesia,  as  in  narcosis  even  a  superficial  com- 
parison of  the  new  fissure  writh  that  of  the  sound  side  is  impossible. 


PTOSIS.  83 

On  the  other  hand,  it  must  be  remembered,  that  in  local  anesthesia 
the  swelling  of  the  tissues  through  the  subcutaneous  injection  makes 
it  also  rather  difficult  to  correctly  estimate  the  width  of  the  palpebral 
fissure. 

The  method  of  Panas,  performed  considerably  at  one  time,  for 
cosmetic  reasons  alone  is  inadvisable  and  need  not  be  described. 

The  method  of  Motais,  recommended  recently  by  several  French 
operators,  depends  upon  the  suturing  of  the  superior  rectus  to  the 
upper  margin  of  the  tarsus.  It  has  the  great  disadvantage  of  inter- 
fering with  the  function  of  this  muscle;  and  a  permanent  diplopia  may 
follow  its  performance. 


CHAPTER  VIII. 
THE  EYE-MUSCLES. 

TENOTOMY. 

In  tenotomy  of  the  rectus  interims,  the  left  hand,  holding  a 
pair  of  toothed  forceps,  raises  a  fold  of  the  bulbar  conjunctiva  at  a 
distance  of  3  mm.  from  the  limbus.  A  short  vertical  incision,  about 
5-7  mm.  long,  is  made  with  a  small,  slightly  curved  scissors.  The 
nasal  border  of  the  wound  is  then  lifted  up  with  the  forceps  and  the 
subconjunctival  tissue  severed  and  undermined  by  short  cuts  with  the 
scissors.  The  closed  forceps,  held  parallel  to  the  sclera,  are  now 
introduced  into  the  wound,  the  internal  margin  of  which  is  slightly 
raised  by  the  assistant  to  facilitate  this  introduction,  till  they  reach  the 
insertion  of  the  muscle  (5  mm.  from  the  limbus).  They  are  then 
opened,  pressed  against  the  sclera,  and  through  shutting  them  the 
tendon  is  grasped.  The  forceps  are  now  rotated  into  a  position  per- 
pendicular to  the  sclera,  and  the  tendon  divided  close  to  its  insertion 
by  the  scissors  held  in  the  right  hand.  In  making  this  division,  one 
blade  of  the  scissors  is  pushed  behind  the  tendon,  as  shown  in  the 
illustration  (Fig.  47). 

Not  a  particle  of  the  tendon  should  remain  adherent  to  the  sclera, 
and  after  its  separation  only  a  slight  ridge  should  mark  its  point  of 
insertion.  The  muscle  is  immediately  released,  as  pulling  with  the 
forceps  is  painful.  The  scissors  are  laid  aside,  and  a  curved  strabis- 
mus hook,  taken  in  the  left  hand,  is  pushed  into  the  wound,  close  to 
the  sclera,  and  moved  upward  and  downward  in  order  to  determine 
whether  all  of  the  tendon-fibers  have  been  severed.  Any  fibers  which 
have  not  been  divided  will  offer  a  tense  resistance  to  the  hook,  when 
the  latter  is  drawn  forward.  These  fibers  must  also  be  separated 
close  to  the  sclera.  If  the  hook  becomes  caught  in  the  capsule  of 
Tenon,  it  pulls  out  a  delicate  membranous  fold,  which  must  not  be 
mistaken  for  tendon-fibers.  Incisions  of  Tenon's  capsule  are  likely  to 
produce  undesirable  results.  After  all  the  fibers  are  separated,  the 
wound  is  closed  with  one  or  two  catgut-sutures,  which  are  introduced 
in  a  direction  from  above  downward.  While  the  needle  is  being  passed 

84 


THE  EYE-MUSCLES. 


through 


the  conjunctiva,  the  membrane  should  be  firmly  fixed  with 
the  toothed  forceps  and  the  needle  held  close  against  it,  as  pulling  on 
the  conjunctiva  will  cause  the  patient  unnecessary  pain. 

The  execution  of  the  tenotomy  itself  is  the  work  of  an  instant.  The 
operation  is  best  performed  under  cocain-anesthesia.  The  experi- 
enced operator  may  anesthetize  the  conjunctiva  alone,  by  dropping 


FIG.  47. — Tenotomy  of  the  rectus  internus.  The  eye  is  placed  in  the  position  of 
abduction.  A  small  incision  is  made  in  the  conjunctiva  (c).  The  forceps,  after  seizing 
the  muscle,  are  held  perpendicular  to  the  curvature  of  the  eyeball.  One  blade  of  the  open 
scissors  is  introduced  immediately  behind  the  muscle  at  its  insertion,  the  other  bladejies 
in  front  of  it.  A  single  snip  with  the  scissors  severs  the  tendon  (t)  at  its  insertion. 


the  cocain-solution  into  the  eye.  In  sensitive  patients,  or  if  the  operator 
is  inexperienced,  it  will  be  advisable  to  make  a  subconjunctival  injec- 
tion of  a  i  per  cent,  solution  of  cocain  immediately  over  the  tendon  of 
the  muscle,  employing  a  quantity  of  ^  cc.  The  manner  of  holding  the 
instruments  is  the  same  whether  the  tenotomy  is  performed  on  the 
right  eye  or  the  left  eye.  After  the  operation  a  slight  dressing  is 


86  OPHTHALMIC    SURGERY. 

applied  which  may  be  removed  the  following  day,  or  at  most  two  or 
three  days  later. 

In  tenotomy  of  the  external  rectus  the  incision  through  the  con- 
junctiva is  made  slightly  further  from  the  limbus,  on  account  of  the 
more  remote  insertion  of  the  tendon  of  this  muscle  (7  mm.  instead  of 
5  mm.).  Otherwise,  the  technique  of  the  operation  is  exactly  the 
same. 

ADVANCEMENT. 

In  the  operation  of  advancement  the  conjunctival  sac  is  first  cocain- 
ized, followed  in  every  case  by  a  subconjunctival  injection  of  a  3  per 
cent,  solution  of  cocain  (^  cc.).  A  fold  of  conjunctiva  is  lifted  up 
over  the  tendon  of  the  muscle,  and  the  needle  of  the  syringe  introduced 
against  the  sclera  and  directed  along  the  axis  of  the  muscle  toward  the 
canthus.  While  this  injection  is  being  made,  the  needle  must  be  pushed 
farther  in,  in  order  to  better  anesthetize  the  deeper  parts.  The 
resultant  swelling  may  be  dispersed  by  slight  massage. 

Sufficient  space  for  the  performance  of  the  operation  is  obtained 
by  a  short  vertical  incision  through  the  conjunctiva,  as  in  tenotomy, 
in  addition  to  which  a  long  horizontal  incision  is  made,  beginning 
at  the  middle  of  the  first  cut,  and  running  perpendicular  to  it  toward 
the  canthus.  The  wound  is  thoroughly  undermined  by  small  cuts 
with  the  scissors,  after  which  the  muscle  is  seized  with  the  forceps  in 
the  manner  previously  described. 

The  tendon  is  now  held  with  the  forceps,  and  the  eye  is  rotated  in 
the  direction  opposite  to  the  action  of  the  muscle,  while  the  latter  is 
loosened  from  its  bed  by  a  few  strokes  with  the  point  of  the  closed 
scissors,  which  is  made  to  glide  along  its  upper  and  lower  margins.  A 
straight  strabismus  hook  is  then  passed  beneath  the  muscle,  either  from 
above  or  below.  If  the  point  of  the  hook  is  covered  by  the  conjunctiva 
or  the  capsule  of  Tenon,  it  must  be  freed,  and  the  second  strabismus 
hook  is  thereupon  introduced  in  the  opposite  direction.  Muscle- 
fibers  will  frequently  be  caught  by  this  hook  which  escaped  the  first 
one.  If  the  muscle  is  not  yet  cleanly  dissected,  the  overlying  tissue 
must  be  separated  with  the  scissors,  the  cutting  always  following  the 
direction  of  the  muscle.  If  it  is  done  transversely,  that  is,  vertical  to 
the  muscle-fibers,  it  may  happen  that  a  considerable  part  and  some- 
times even  the  entire  muscle  is  severed,  thus  making  the  operation 
much  more  complicated.  It  is  important  for  the  assistant  to  remember 


THE  EYE-MUSCLES.  87 

that  he  should  stretch  the  muscle  by  means  of  the  two  strabismus-hooks 
only  when  desired  by  the  operator,  as  tension  on  the  muscle  always 
causes  pain. 

The  suturing  is  now  done.  While  the  sutures  are  being  inserted, 
the  assistant  must  stretch  the  muscle.  This  is  effected  by  the  anterior 
strabismus  hook  drawing  the  eye  in  a  direction  opposite  to  the  action 
of  the  muscle,  while  the  other  strabismus  hook  is  moved  in  the  direc- 
tion of  the  musclar  contraction.  A  moderately  thick  silk  thread, 


FIG.  48. — The  eye  is  placed  in  the  position  of  adduction.  The  freed  muscle  is  stretched 
over  two  strabismus-hooks.  The  upper  suture  has  already  been  pulled  through;  the  lower 
suture  is  being  introduced. 

upon  the  strength  of  which  we  can  rely  with  certainty,  is  used.  The 
threaded  needle  is  passed  from  within  outward  through  the  muscle 
near  its  middle  close  to  the  posterior  strabismus-hook.  Half  of  the 
suture  is  drawn  through,  and  the  needle  is  again  passed  in  the  same 
manner  at  the  same  point.  The  loop  thus  formed  is  made  to  firmly 
grasp  the  muscle-fibers.  It  makes  no  difference  whether  the  needle 
is  first  passed  through  the  upper  or  lower  half  of  the  muscle.  The 
other  half  of  the  muscle  is  then  included  in  a  loop  of  thread  intro- 
duced at  the  same  distance  from  the  insertion  of  the  tendon  (Fig.  48) 


88  OPHTHALMIC    SURGERY. 

and  laced  up  in  the  same  manner.  The  ends  of  the  suture  containing 
the  upper  half  of  the  muscle  are  laid  upward,  and  those  of  the  lower 
half  downward,  or  a  white  and  a  black  suture  may  be  used  in  order 
that  the  wrong  ends  of  the  threads  may  not  be  tied,  when  this  stage 
of  the  operation  is  reached.  After  the  sutures  are  introduced,  the 
operator  divides  the  muscle  with  one  snip  of  the  scissors,  about  2  mm. 
in  front  of  the  threads;  closer  than  this,  the  loops  are  liable  to  slip  off. 
The  stump  of  the  muscle  still  adhering  to  the  sclera,  is  now  removed 
close  to  the  scleral  surface,  leaving  only  a  short  piece  at  one  end  of  the 
insertion,  to  allow  fixation  of  the  eye  with  the  forceps. 

By  the  foregoing  procedures,  it  is  seen  that  the  muscle  is  shortened 
to  a  certain  extent,  and  it  must  now  be  not  only  re-attached  to  the 
bulb,  but  fastened  so  that  its  influence  is  more  strongly  felt,  i.e.,  its 
insertion  must  be  brought  nearer  to  the  limbus,  hence  the  term: 
advancement.  For  this  purpose,  the  needle  of  either  suture  is  passed 
near  the  limbus  through  the  superficial  layers  of  the  sclera,  the  thread 
of  the  upper  loop  corresponding  to  the  upper  half  of  the  original 
insertion,  and  vice  -versa.  The  sclera  in  front  of  the  insertion  must 
first  be  laid  bare  by  separation  of  the  conjunctiva,  as  the  muscle 
naturally  can  only  unite  with  a  raw  surface.  For  this  suture,  it  is 
best,  to  employ  a  thin  flat  needle,  not  the  thick  and  triangular  needles, 
as  these  would  have  to  be  introduced  deeply  to  prevent  cutting  through. 

With  a  normally  thick  sclera  there  is  no  danger  of  perforating 
the  bulb,  if  the  needle  is  held  parallel  to  the  curvature  of  the  sclera, 
so  that  only  the  most  superficial  layers  are  taken  up.  The  needle 
point  must  not  be  placed  vertically  against  the  sclera  in  order  to  pene- 
trate its  fibers.  The  only  unpleasant  feature  is  that  the  needle  may  be 
passed  too  superficially  and  soon  cuts  through.  If  this  happens,  a 
fresh  attempt  must  be  made  to  catch  some  of  the  adjacent  scleral 
fibers,  a  few  of  which  are  sufficiently  strong  to  allow  the  operator  to 
draw  the  eye,  by  means  of  the  suture,  in  the  direction  of  the  muscle 
and  to  fasten  the  latter  firmly  to  the  globe.  In  making  this  suture, 
the  needle  is  inserted  in  the  direction  of  the  muscle,  i.e.,  horizontally, 
and  the  thread  fastened  to  the  sclera  in  front  of  either  the  upper  or 
the  lower  half  of  the  tendon-insertion,  according  to  which  suture  is 
being  tied.  The  attachment  is  made  as  close  as  possible  to  the  limbus, 
but  care  should  be  taken  that  the  knotted  thread  does  not  injure  the 
cornea  by  pressure.  The  position  of  the  knot  should,  therefore,  be  at 
least  i  mm.  from  the  limbus,  so  that  it  does  not  press  upon  the 


THE  EYE-MUSCLES. 


89 


cornea.  For  this  reason,  it  is  advisable,  and  for  the  less  skillful 
operator  easier,  to  pass  the  needle  through  the  sclera  parallel  to  the 
limbus,  i.e.,  perpendicular  to  the  axis  of  the  muscle.  The  needle  of 
the  superior  suture  must,  therefore,  be  brought  from  the  horizontal 
meridian  upward,  while  that  of  the  inferior  suture  goes  from  the 
same  point  downward.  Such  a  direction  of  the  sutures  has  also  the 


FIG.  49. — Advancement  of  the  rectus  externus.  The  muscle  is  divided;  a  piece 
excised;  the  eye  is  held  fast  by  forceps  applied  to  the  stump  of  the  tendon,  which  has  been 
allowed  to  remain.  The  upper  suture  has  already  been  drawn  through  the  sclera  near 
the  limbus  and  also  through  the  conjunctiva.  The  needle,  which  has  been  applied  flat 
against  the  sclera,  has  already  penetrated  slightly  the  superficial  lamellae. 


advantage  of  lying  perpendicular  to  the  direction  of  the  scleral  fibers 

(Fig-  49)- 

After  the  needle  has  been  fixed  into  the  sclera,  it  is  passed  a  little 
further  upward  or  downward  through  the  conjunctiva.  This  affords 
not  only  an  additional  hold  for  the  suture,  if  the  attachment  to  the 
sclera  is  not  sufficiently  firm,  but  closes  simultaneously  the  wound  in 


9o 


OPHTHALMIC    SURGERY. 


the  conjunctiva.     Only  one  end  of  each  suture  is  passed  through  the 
sclera. 

Now  a  surgical  sling  is  prepared  in  both  the  upper  and  the  lower  su- 
tures. Then,  while  the  assistant  seizes  with  the  forceps  the  eyeball  at 
the  opposite  limbus  and  rotates  the  bulb  in  the  direction  of  the  operated 
muscle,  each  suture  is  drawn  as  tight  as  possible,  and  a  second  knot 
is  made  over  the  first  (Fig.  50).  The  sutures  must  be  dra\vn  firmly 
in  order  to  be  certain  that  the  muscle  has  actually  been  brought  for- 


FIG.  50. — The  operation  is  almost  completed.  The  eye  is  rotated  outward  by  the 
forceps,  which  are  fastened  at  the  inner  side.  The  lower  suture  has  already  been  tied; 
the  upper  has  still  to  be  pulled  together.  The  conjunctiva  covers  the  wound  spontaneously . 


ward  to  the  limbus  and  fastened  there.  If  the  sutures  have  not  been 
brought  together  properly,  the  muscle  will  be  weakened  rather  than 
strengthened  by  the  advancement. 

A  suture  of  the  conjunctiva  is  usually  unnecessary  as  the  wTound  has 
already  been  closed  perfectly  by  the  advancement-sutures.  If  this,  in  an 
isolated  instance,  should  not  be  the  case,  there  is  no  objection  to  a  con- 
junctival  suture.  The  operation  is  the  same  for  either  the  rectus  inter- 
nus  or  externus.  The  threads  are  cut  off  short,  and  care  exercised  that 


THE  EYE-MUSCLES.  91 

they  do  not  come  in  contact  with  the  cornea.  After  the  operation  a 
dressing  is  applied  to  both  eyes,  as  the  prevention  of  all  ocular  motion 
will  protect  the  recently  sutured  muscle  in  its  new  position  and  make 
secure  its  attachment  to  the  limbus. 

After-treatment. — When  possible,  as  in  hospital-cases,  both  eyes 
should  be  kept  closed  for  three  days,  but  the  dressing  is  changed  on  the 
day  following  the  operation,  in  order  to  ascertain  whether  or  not  the 
cornea  is  uninjured.  The  sutures  may  be  removed  on  the  fifth  or 
sixth  day  after  the  operation,  but  if  a  pronounced  swelling  of  the  con- 
junctiva prevents  ready  access  to  the  knots,  there  is  no  objection  to 
allowing  the  sutures  to  remain  longer,  as  they  can  be  removed  later 
with  much  greater  facility.  On  the  whole,  the  reaction  of  the  conjunc- 
tiva to  this  operation  is  usually  slight.  The  eye  exhibits  no  irritation 
or  pain,  and  in  a  short  time  there  is  only  a  slight  thickening  of  the  con- 
junctiva to  mark  the  point  of  operative  interference. 

If  the  patient's  sound  eye  cannot  be  bandaged  (as  in  the  case  of 
ambulant  patients,  who  must  go  home  alone), it  is  advisable  to  keep  the 
muscle  at  rest  by  introducing  a  suture  through  the  conjunctiva  close  to 
the  limbus,  and  carrying  the  ends  through  the  canthus  to  the  external 
skin,  where  they  are  tied.  In  this  way  it  becomes  impossible  to  rotate 
the  eye  toward  the  side  opposite  to  that  of  the  advanced  muscle. 

The  Fixation  of  the  Muscle  to  the  Limbus. — While  it  is  our  custom 
to  suture  the  muscle  directly  to  the  sclera,  by  passing  the  needle 
through  its  most  superficial  layers,  as  has  been  described,  it  is  proper 
to  discuss  here  another  common  method.  This  consists  in  passing 
one  end  of  the  upper  suture  upward  beneath  the  conjunctiva  along 
the  limbus,  going  almost  as  far  as  the  upper  end  of  the  vertical  meridian, 
and,  in  a  similar  manner,  one  end  of  the  inferior  suture  is  passed  be- 
neath the  conjunctiva  as  far  as  the  lower  end  of  the  vertical  meridian. 
In  this  way  an  attempt  is  made  to  obtain  sufficient  hold  for  the  muscle 
in  the  conjunctiva.  When  the  sutures  are  tied,  the  muscle  is,  of  course, 
drawn  forward  to  the  limbus,  and  must  naturally  split.  On  the 
other  hand,  the  ocular  conjunctiva  also  yields  to  the  tension,  and  is 
stretched  in  the  direction  of  the  tendon,  obliquely  across  the  cornea. 
Quite  apart  from  the  fact  that  this  attachment  is  not  dependable,  on 
account  of  occasional  friability  of  the  conjunctiva,  the  method  has  still 
a  greater  drawback — namely,  that  the  conjunctiva  lies  from  above- 
downward  in  a  tensely  drawn  fold  across  the  cornea.  Again,  it  can 
easily  happen  that  the  suture  will  come  to  lie  upon  the  cornea,  especially 


92  OPHTHALMIC    SURGERY. 

if  it  is  not  drawn  sufficiently  tight,  a  fact  which  may  pass  unnoticed  by 
the  operator,  as  the  knot  is  covered  by  the  conjunctiva.  A  corneal 
ulcer  may  thus  be  produced,  which  will  make  the  prognosis  bad,  as 
these  ulcers  show  little  tendency  to  heal.  The  operator  is  then  forced 
to  remove  the  sutures  at  once  sacrificing  the  entire  success  of  the 
advancement.  Therefore,  preference  should  be  given  absolutely 
to  the  direct  suturing  to  the  sclera.  The  only  contraindication  to  this 
would  be  a  pathologically  thinned  sclera  (ectasia) . 

APPLICABILITY  OF  STRABISMUS-OPERATIONS. 

Before  performing  a  strabismus  operation,  two  conditions  should  be 
investigated— the  degree  of  deviation  of  the  affected  eye,  and  the 
mobility  of  the  eyes.  It  may  be  incidentally  mentioned  at  this  time  that 
a  preliminary  accurate  determination  of  the  ocular  refraction 
under  the  influence  of  atropin  is  an  absolute  necessity.  The  same 
degree  of  strabismus  may  in  one  case  call  for  a  tenotomy,  and  in  another 
make  an  advancement  of  the  muscle  desirable.  Furthermore,  it  must  be 
clearly  understood  how  much  effect  is  likely  to  be  produced  by  a  tenotomy 
or  an  advancement.  For  example,  how  many  degrees  of  the  squint  in 
an  eye  with  convergent  strabismus  may  be  overcome  by  a  correctly  per- 
formed tenotomy  of  the  rectus  internus,  and  how  many  by  an  advance- 
ment of  the  rectus  externus  ?  The  exact  determination  of  this  is  not 
possible.  It  is  commonly  believed  that  tenotomy  of  the  rectus  internus 
corrects  to  the  extent  of  15  degrees,  but  very  often  there  is  produced 
decidedly  less  correction,  sometimes  even  very  much  less.  And,  while 
at  times  the  final  result  of  a  tenotomy  after  the  lapse  of  some  time  shows 
little  change  in  the  degree  of  squint,  in  other  cases  the  effect  is  unex- 
pectedly great,  so  that  the  commonly  given  figures  are  far  exceeded. 
As  stated  clearly  above,  this  applies  only  to  a  correctly  performed 
tenotomy.  It  would  not  be  surprising  to  find  an  enormous  change  in 
the  position  of  the  eye  after  extensive  incisions  of  the  conjunctiva,  the 
subconjunctival  tissue  and  Tenon's  capsule,  or  to  get  no  result  at  all 
when  some  of  the  muscle-fibers  were  overlooked.  But  even  in  per- 
forming the  operation  in  the  most  approved  manner,  the  effect  may 
be  decidedly  influenced,  not  only  by  preexisting  physiologic  variations 
in  the  distance  of  the  muscular  insertion  from  the  limbus,  in  the 
strength  of  the  muscle,  and  in  the  relations  of  Tenon's  capsule,  but 
also,  and  sometimes  to  a  considerable  degree,  by  definite  even  though 
only  slight  variations  in  the  degree  of  separation  of  the  subconjunctival 


THE  EYE-MUSCLES.  93 

tissue  and  capsule  resulting  from,  the  operation.  It  must  also  be 
remembered  that  the  immediate  result  of  an  operation  may  differ 
greatly  from  the  more  remote,  permanent  result. 

From  the  foregoing  it  is  readily  understood  that  the  degree  of  cor- 
rection after  tenotomy  of  the  rectus  internus  cannot  be  foretold  with 
certainty.  But  even  if  the  effect  of  a  tenotomy  were  definitely 
known  in  advance,  there  would  still  remain  many  perplexing  problems 
for  the  operator.  It  would  naturally  be  most  uncommon  for  the  degree 
of  a  strabismus  to  correspond  exactly  with  the  degree  of  change  in 
position  produced  by  severance  of  the  tendon.  Therefore,  the  neces- 
sity for  some  means  of  regulating  the  effect  of  a  strabismus  operation 
is  at  once  recognized.  With  such  means  at  hand  one  does  not  need  to 
know  accurately  in  advance  how  much  effect  the  operation  will  have. 
Hence,  for  altering  the  effect  of  a  tenotmoy  there  are  introduced  what 
are  termed  supporting  and  counteracting  sutures. 

The  supporting  suture  is  inserted  by  means  of  a  short,  moderately 
curved  needle,  into  the  conjunctive  close  to  the  external  limbus  in  the 
horizontal  meridian.  In  this  situation  the  conjunctiva  is  firmly  attached 
to  the  coats  of  the  eye.  If  the  suture  is  placed  more  externally  only  a  fold 
of  conjunctiva  will  be  pulled  forward  by  it,  and  it  will  be  impossible 
for  it  to  exert  an  appreciable  influence  upon  the  position  of  the  eye. 
The  suture  is  introduced  in  the  horizontal  meridian,  because  the  eye 
should  be  rotated  outward  accurately  on  its  vertical  axis;  if  the  fixation 
is  made  above  or  below  the  horizontal  meridian,  the  rotating  of  the  eye 
will  occur  on  other  axes,  which  would  produce  undesirable  results. 
In  order  to  fasten  the  suture  firmly,  it  is  advisable  to  introduce  the 
needle  twice,  once  immediately  above  and  once  just  below  the  horizon- 
tal meridian.  In  those  occasional  cases  in  which  the  conjunctiva  is 
easily  lacerated,  there  should  be  no  hesitation  in  penetrating  somewhat 
deeper  with  the  needle  in  order  to  fasten  the  suture  in  the  episcleral 
tissue  beneath  the  conjunctiva.  Both  ends  of  the  silk-suture  are  then 
passed  in  the  horizontal  meridian  through  the  external  canthus  out 
to  the  skin.  In  doing  this,  the  needle  is  made  to  penetrate  the  can- 
thus  rapidly,  while  the  outer  angle  of  the  eye  is  stretched  between  two 
fingers.  By  tying  both  ends  of  the  suture  finally  over  a  small  gauze 
compress,  the  operator  is  in  a  position  to  rotate  the  eye  outward 
at  will. 

The  problems  now  confronting  the  operator  are  the  following: 
How  far  outward  should  the  eye  be  rotated  ?  How  great  is  the  effect 


94  OPHTHALMIC    SURGERY. 

of  this  supporting  suture,  and  when  should  it  be  applied  ?  The  appli- 
cation of  the  suture  is  naturally  limited  to  those  cases  in  which  con- 
vergent strabismus  still  exists  after  the  tenotomy  but  in  which  at  the 
same  time  the  loosened  muscle  is  not  too  much  limited  in  its  efficiency. 
It  follows,  as  a  matter,  of  course,  and  this  is  an  important  rule  after 
every  strabismus-operation,  that  the  position  of  the  eye  should  be  con- 
trolled immediately  after  completion  of  the  operation.  This  is  best 
done  by  having  the  patient,  while  still  lying  on  the  operating  table,  fix 
his  gaze  with  both  eyes  open  upon  a  point  on  the  ceiling  of  the  room. 
It  can  then  be  readily  determined  how  much  improvement  in  position 
has  been  accomplished  by  the  operative  interference.  Then,  by  having 
the  patient  fix  upon  the  operator's  finger,  while  it  is  moved  toward  him 
in  the  sagittal  plane,  the  convergence-ability  of  the  eye  can  be  deter- 
mined, and,  by  laterally  conducted  movements,  also  the  adduction- 
power  of  the  severed  muscle.  The  suture  should  not  be  used  in  those 
cases  in  which  the  muscle  appears  considerably  weakened,  even  though 
there  still  remains  some  strabismus.  As  the  suture  rotates  the  eye 
outward,  the  insertion  of  the  muscle  will  come  to  lie  still  further  from 
the  limbus  than  after  a  simple  tenotomy,  and  through  this  the  muscle 
will  lose  still  more  in  efficiency.  If  there  is  pronounced  weakness  of 
the  muscle,  a  divergent  squint  will  soon  develop,  owing  to  the  marked 
preponderance  in  strength  of  the  intact  rectus  externus. 

In  accordance  with  the  rule  always  to  be  satisfied  with  a  slight 
undercorrection  in  the  operation  for  convergent  squint,  the  eye  should 
not  be  rotated  outward  to  its  greatest  extent  by  means  of  the  suture, 
although  it  is  known  that  the  eye  rolls  inward  again  after  removal  of 
the  suture.  At  the  most,  therefore,  it  is  permissible  to  pull  the  suture 
sufficiently  tight  to  produce  a  slightly  divergent  position.  It  is  not 
necessary  to  allow  the  suture  to  remain  over  twenty-four  hours.  The 
final  effect  of  the  suture  cannot  be  estimated  accurately  in  degrees. 
As  already  mentioned,  the  eye  usually  rolls  inward  again  to  a  slight 
extent.  The  influence  of  the  supporting  suture  is  closely  related  to 
the  size  of  the  incision  into  Tenon's  capsule.  Lateral  incisions  in 
the  capsule  of  Tenon,  which  are  also  recommended  to  increase  the 
effect  of  tenotomy,  must  certainly  be  made  to  some  extent  in  the 
performance  of  every  tenotomy. 

A  great  advantage  lies  in  the  possibility  of  introducing  this  suture 
one,  two,  or  even  three  days  after  the  tenotomy.  It  happens  occasion- 
ally that  the  correction  produced  by  a  tenotomy  is  entirely  satisfactory 


THE  EYE-MUSCLES. 


95 


immediately  after  the  operation,  but  in  the  next  few  days,  to  the  great 
astonishment  of  the  operator,  the  effect  diminishes  considerably  and  the 
degree  of  strabismus  increases  correspondingly.  The  suture  is,  there- 
fore, the  most  acceptable  means  of  reproducing  the  original  result. 
After  cocainizing  and  re-opening  the  conjunctival  wound,  a  strabismus 
hook  is  employed  to  separate  the  fresh  adhesions  that  have  formed 
since  the  operation,  after  which  the  suture  may  usually  be  introduced 
with  gratifying  results. 

The  counteracting  suture  is  applied  as  follows:  A  suture  is  intro- 
duced through  the  conjunctiva  close  to  the  internal  limbus,  in  the  same 
manner  as  previously  described  for  the  supporting  suture  at  the  external 
limbus.  The  inner  border  of  the  wound  is  then  raised  by  means  of 
toothed  forceps,  and  if  a  pronounced  effect  is  desired,  an  attempt  is 
made  to  grasp  the  muscle  itself  with  the  forceps.  The  needle  is  then 
pushed  deeply  into  the  subconjunctival  tissue  and  is  brought  out  near 
the  internal  canthus  about  the  point  of  the  caruncle.  The  whole  region 
must  previously  be  anesthetized  by  a  cocain-injection.  The  other 
end  of  the  suture  is  passed  in  the  same  way,  and  the  two  ends  are 
tied  firmly.  The  eye  is  thereby  rotated  inward,  so  that  the  recently 
divided  muscle  with  its  tendon  is  again  brought  closer  to  the  limbus, 
and  thus  gains  in  power.  The  fixation  of  the  silk-thread  in  the  con- 
junctiva at  the  limbus  is  sometimes  difficult,  particularly  if  the  con- 
junctival incision  has  been  made  close  to  the  limbus.  If  the  con- 
junctiva is  easily  torn,  and  does  not  offer  sufficient  hold  for  the  suture, 
no  other  course  is  left  open  but  to  fasten  the  suture  in  the  superficial 
layers  of  the  sclera. 

This  suture  must  invariably  be  employed  if  an  over-correction  has 
resulted  from  the  tenotomy.  If  the  eye  shows  a  tendency  to  become 
divergent  immediately  after  the  division  of  the  tendon,  and  if  the  powers 
of  adduction  and  convergence  of  the  eye  have  been  greatly  interfered 
with  by  the  operation,  the  omission  of  this  suture  would  constitute  a 
serious  mistake.  The  highest  grades  of  divergent  squint  may  follow 
such  unfortunate  tenotomies.  As  in  the  case  of  the  supporting  suture, 
this  counteracting  suture  may  also  be  introduced  one  to  three  days  after 
the  tenotomy.  It  is  only  necessary  first  to  break  any  existing  adhesions 
by  means  of  the  strabismus  hook.  The  suture  is  always  tied  firmly  so 
that  it  produces  a  decided  convergent  position  of  the  eye.  In  over- 
correction  of  the  eye,  it  is  not  likely  that  too  much  counteraction  will  be 
produced.  The  suture  should  be  allowed  to  remain  several  days. 


96  OPHTHALMIC    SURGERY. 

As  mentioned  before,  all  of  the  methods  described  here  refer  to  tenotomy 
of  the  rectus  internus. 

Tenotomy  of  the  external  rectus  plays  a  much  less  important  part 
in  the  operation  for  divergent  strabismus,  than  does  tenotomy  of  the 
internal  rectus  in  the  operation  for  convergent  strabismus.  This 
subject  will  be  considered  later,  and  in  the  meantime  the  discussion 
will  be  continued  regarding  the  operation  for  convergent  strabismus. 

The  Extent  of  the  Effect  Produced  by  Advancement  of  the 
Rectus  Externus. — Still  less  accurate  figures  can  be  given  here  than 
in  the  case  of  tenotomy.  The  variations  in  the  extent  of  the  results 
should  not  occasion  surprise,  and  it  would  be  extremely  naive,  if  we 
could  believe  that  each  millimeter  of  excised  muscle  will  produce  ex- 
actly the  same  degree  of  correction  in  every  case,  or  that  a  certain  degree 
of  strabismus  will  be  overcome  by  the  excision  of  so  many  millimeters 
of  muscle  in  accordance  with  an  inflexible  rule.  A  change  of  30 
degrees  in  the  position  of  the  eye  is  the  most  that  can  be  expected 
from  an  advancement;  usually  it  is  much  less,  and  may  be  put  down 
at  20  degrees  at  an  average  in  an  operation  with  normal  course. 

In  the  method  which  has  been  described,  there  are  two  means  of 
influencing  the  effect  of  advancement — the  excision  of  a  piece  of 
muscle,  and  the  suture  of  the  insertion  in  front  of  the  original  point  of 
attachment.  The  last  plays  a  more  important  part  than  the  excision. 
If  the  operation  is  limited  merely  to  the  excision  of  part  of  the  muscle, 
and  the  muscle  again  sutured  to  the  original  point  of  insertion,  the 
effect  of  the  operation  will  be  slight.  Of  decided  importance  is  the 
approaching  of  the  new  point  of  insertion  of  the  muscle  toward  the 
limbus. 

There  is  no  danger  of  producing  an  over-correction  by  performance 
of  advancement  alone.  Even  in  a  convergent  strabismus  of  no  more 
than  20  degrees  one  may  safely  excise  the  longest  possible  piece  of  the 
muscle  and  suture  the  remainder  in  an  advanced  position  without 
producing  thereby  a  divergent  strabismus.  It  must  also  be  taken  into 
consideration  that  the  result  evident  immediately  after  the  operation 
is  at  its  maximum,  and  that  the  effect  usually  diminishes  somewhat 
in  the  near  future.  Therein  lies  an  important  contrast  with  the  effect 
of  a  tenotomy.  While  an  over-correction  must  be  strictly  avoided  in  the 
performance  of  tenotomy,  on  account  of  the  increasing  degree  of  diver- 
gent strabismus  that  is  inevitably  produced,  any  over-correction  that 
may  occur  during  the  performance  of  an  advancement  need  not  worry 


THE  EYE-MUSCLES.  97 

the  operator.  No  increase  in  the  divergence  is  to  be  expected;  on  the 
contrary,  a  retrogression  is  certain  to  occur. 

Incalculable  results  may  follow  simultaneous  advancement  of  the 
rectus  externus  and  tenotomy  of  the  rectus  internus  of  one  eye. 
Even  though  a  considerable  degree  of  convergent  squint  with  good 
adduction-power  of  the  eye  remains  after  a  tenotomy  of  the  internal 
rectus,  an  immediate  advancement  of  the  rectus  externus  is  a  risky 
procedure.  The  effect  accomplished  is  often  enormous,  and  a  high 
degree  of  divergent  strabismus  may  be  the  immediate  result.  As  a 
result  of  the  preliminary  tenotomy,  the  advancement  not  only  produces 
changes  in  the  region  of  the  external  rectus,  but  also  weakens  the  action 
of  the  internal  rectus.  Through  advancement  of  the  rectus  externus 
the  eye  is  rotated  outward,  and  owing  to  the  lack  of  resistance  on  the 
part  of  the  divided  rectus  internus,  this  rotation  is  greater  than  it  would 
be  with  a  normal  internal  rectus.  The  result  is  necessarily  the  same 
as  that  produced  by  a  supporting  suture.  The  rectus  internus  is  drawn 
further  away  from  its  original  point  of  insertion  toward  the  equator  of 
the  eye,  and  loses  correspondingly  in  its  influence. 

The  simultaneous  performance  of  tenotomy  and  advancement  can 
be  recommended  only  for  the  highest  grades  of  convergent  strabismus. 
Even  in  these  cases  the  operation  has  to  be  limited  to  a  resection  of  the 
muscle,  and  the  suture  made  through  the  original  point  of  insertion. 
If  an  over-correction  is  produced,  it  should  by  no  means  be  allowed 
to  remain,  as  the  resulting  divergent  strabismus  will  rapidly  increase 
in  degree.  It  is  necessary  to  introduce  immediately  a  counteracting 
suture,  which  must  be  well  buried  in  the  superficial  layers  of  the  sclera 
at  the  internal  limbus,  to  prevent  the  thread  from  tearing  out.  Should 
this  not  be  sufficient,  the  operator  must  remove  the  sutures  of  the 
advancement  and  fasten  the  muscle  further  backward.  The  removal  of 
these  sutures  after  an  interval  of  two  or  three  days  will  no  longer  have 
any  effect  on  the  result  of  the  operation. 

From  a  physiologic  standpoint,  advancement  must  be  given  the 
preference.  It  increases  the  motility  of  the  eye,  while  tenotomy  causes 
a  diminution  or  loss  in  motility.  Therefore,  although  the  pathogene- 
sis  of  strabismus  may  indicate  tenotomy  as  the  operation  of  choice  for 
the  correction  of  convergent  squint,  advancement  must  be  recognized 
as  of  greater  value  physiologically.  This  should  not  be  understood, 
however,  as  meaning  that  an  advancement  must  be  performed  under 
7 


98  OPHTHALMIC    SURGERY. 

all  circumstances;  in  fact,  it  cannot  be  denied  that  in  many  cases  tenot- 
omy  is  an  indispensable  operation. 

In  order  to  give  some  general  indications  for  procedure 
in  overcoming  convergent  strabismus,  the  following  rules  may 
be  formulated,  based  upon  the  preceding  considerations: 

If  the  squinting  eye  is  amblyopic,  the  operations  are  preferably 
performed  upon  this  eye,  so  far  as  the  consideration  for  its  mobility 
will  allow;  however,  an  interference  with  the  other  eye  is  usually  allow- 
able. 

In  convergent  strabismus  of  slight  degree  (maximum  15  degrees) 
tenotomy  of  the  rectus  internus  of  the  affected  eye  is  the  first  con- 
sideration. An  examination  of  the  new  position  of  the  eye  must  be 
made  immediately  after  the  operation  and  in  accordance  with  the 
points  of  view  previously  pointed  out,  in  order  to  determine  whether 
or  not  a  suture,  and  which  suture,  is  necessary  to  change  the  effect. 
Only  rarely  will  it  be  found  that  the  tenotomy  has  produced  exactly 
the  result  desired.  If  the  tenotomy  is  succeeded  by  a  marked  diminu- 
tion in  the  motive  power  of  the  rectus  internus,  all  thought  of  immediate 
further  interference  must  be  abandoned,  even  though  a  convergent 
squint  still  remains. 

Tenotomy  is  the  operation  of  choice  in  cases  with  normal  motility 
of  the  squinting  eye,  while  advancement  is  preferable  if  the  abductive 
power  of  the  eye  is  materially  limited.  An  advancement  of  the  rectus 
externus  on  both  sides  may  be  advisable  if  a  unilateral  operation  does 
not  produce  sufficient  correction,  or  if  abduction  is  weak  on  both  sides, 
as  happens  not  infrequently  in  alternating  convergent  strabismus. 
The  extent  of  the  second  advancement  depends  naturally  upon  the 
degree  of  convergent  squint  remaining.  That  an  over-correction  is 
not  to  be  feared,  has  already  been  mentioned. 

With  strabismus  of  higher  degree,  in  which  it  is  foreseen  that  neither 
tenotomy  alone  nor  advancement  alone  will  suffice,  warning  must  again 
be  given  against  a  simultaneous  performance  of  both  operations. 
In  such  cases  the  patient  should  be  told  in  advance  that  two  operative 
procedures  will  be  necessary  to  overcome  the  squint.  The  tenotomy 
is  first  performed,  with  supporting  suture  if  necessary.  The  patient 
is  then  allowed  to  go  about  wearing  fully  correcting  lenses  for  several 
weeks,  by  which  time  the  final  result  of  the  operation  will  be  manifest. 
The  advancement  may  then  be  performed,  the  amount  of  advance 
varying  with  the  degree  of  strabismus  still  existing.  If,  after  the  tenot- 


THE  EYE-MUSCLES.  99 

omy,  it  is  seen  that  the  rectus  interims  may  not  be  further  weakened 
directly  or  indirectly  by  a  strengthening  of  the  antagonist,  then  the 
operation  should  be  performed  on  the  other  eye.  It  would  be  worth 
the  attempt  to  determine  how  far  an  advancement  of  the  rectus  exter- 
nus  could  be  influenced  in  a  strengthening  sense  by  a  simultaneous 
partial  tenotomy  of  the  rectus  internus,  thus  avoiding  the  danger  of  over- 
correction  which  accompanies  tenotomy.  The  simultaneous  per- 
formance of  tenotomy  and  advancement  should  be  reserved  for  the 
highest  grades  of  convergent  strabismus  only,  the  advancement  being 
performed  with  the  foregoing  precautions.  This  has  also  to  be  done 
in  those  cases  of  medium  degrees  in  which  we  are  compelled  to  correct 
the  strabismus  in  one  sitting,  either  through  the  request  of  the  patien 
or  for  some  other  reason. 

The  advice  relative  to  the  operation  for  divergent  strabis- 
mus is  much  simpler.  The  precept,  which  applies  chiefly  here,  is 
to  produce  an  over-correction;  but  this  desideratum  is  not  so  easily 
attained.  It  must  be  remembered  that  advancement  of  the  rectus 
internus  is  the  only  procedure,  \vhich  has  any  material  influence  on  a 
divergent  strabismus.  But  in  itself  an  advancement  oj  the  rectus 
internus  has  not  as  much  influence  on  the  position  oj  the  eye  as  an 
advancement  of  the  rectus  externus. 

Two  circumstances  are  responsible  for  this: 

(i)  On  account  of  the  local  obstruction  it  is  not  possible  to  pre- 
pare and  free  as  large  a  part  of  this  muscle  as  in  the  case  of  the 
external  rectus,  and  consequently  the  suture  cannot  be  introduced  as 
far  back;  (2)  There  is  less  room  to  advance  the  muscle,  as  the  inser- 
tion of  the  tendon  is  normally  near  the  limbus  and  cannot  be  brought 
much  closer  to  it.  In  a  similar  way  a  division  of  the  external  rectus 
has  much  less  influence  on  the  position  of  the  eye  than  a  tenotomy  of 
the  internal  rectus.  As  the  tendon  insertion  of  the  rectus  externus  is 
already  further  removed  from  the  limbus,  its  shifting  by  means  of  a 
tenotomy  will  cause  relatively  much  less  loss  in  the  influence  of  the 
muscle  on  the  motility  of  the  eye,  than  is  the  case  with  the  rectus 
internus.  The  value  of  the  point  of  insertion  grows  in  a  rapidly 
increasing  ratio  as  this  point  approaches  the  limbus. 

From  these  observations  it  follows  that,  even  in  slight  grades  of  diver- 
gent squint,  both  operations  are  usually  performed  simultaneously,  in 
order  to  obtain  immediately  after  the  operation  an  over-correction — 
a  slight  degree  of  convergent  strabismus — as  experience  has  shown,  that 


100  OPHTHALMIC    SURGERY. 

there  is  always  a  tendency  toward  a  return  to  the  divergent  position. 
A  tenotomy  alone  of  the  rectus  externus  has  hardly  any  influence.  In 
higher  grades  of  divergent  strabismus  even  the  simultaneous  perform- 
ance of  both  operations  is  not  sufficient. 

In  such  cases  a  supporting  suture  may  be  employed.  This  is 
introduced  in  a  manner  similar  to  that  described  for  the  counteracting 
suture  in  tenotomy  of  the  rectus  internus.  Or  a  suture  may  be  passed 
externally  through  the  bulbar  conjunctiva,  not  too  close  to  the  limbus, 
carrying  both  ends  out  through  the  palpebral  fissure  toward  the  median 
line.  By  drawing  upon  both  ends  firmly  at  the  same  time,  the  eye  is 
brought  into  a  pronounced  convergent  position,  one  end  being  drawn 
upward  to  the  median  line  of  the  forehead,  and  the  other  over  the  bridge 
of  the  nose  to  the  other  side  of  that  organ,  in  which  positions  both  ends 
are  fastened  with  several  strips  of  plaster.  A  small  piece  of  absor- 
bent cotton  is  placed  beneath  the  lower  thread,  so  that  it  does  not  cut 
into  the  bridge  of  the  nose.  As  the  eye  cannot  be  completely  closed, 
it  should  be  covered  with  a  piece  of  oiled  gutta-percha  paper.  The 
suture  may  be  removed  on  the  following  day.  The  cornea  will  not 
be  injured  by  the  suture,  especially  if  it  has  been  introduced  a  short 
distance  externally  to  the  limbus,  so  that  it  raises  a  small  fold  of  the 
conjunctiva. 

If  the  divergent  position  is  not  yet  corrected  in  spite  of  the  supporting 
suture,  then  the  analogous  operation  on  the  other  eye  is  indicated. 

If  the  divergent  strabismus  is  the  result  of  a  tenotomy  of  the 
rectus  internus  that  has  been  performed  for  convergent  strabismus, 
then  an  advancement  of  the  rectus  internus  usually  produces  an 
excellent  result.  The  preparation  of  the  muscle,  however,  is  somewhat 
more  difficult,  as  it  is  often  inserted  surprisingly  far  back  from  the 
limbus.  It  is  scarcely  possible,  in  such  cases,  to  excise  a  part  of  the 
muscle,  as  there  is  only  sufficient  room  to  introduce  the  sutures.  Never- 
theless, the  result  is  good,  as  the  point  of  insertion  can  be  brought 
forward  a  considerable  distance.  After  an  over-correction  of  convergent 
strabismus  by  tenotomy  of  the  rectus  internus,  the  operator  must  be 
warned  against  undertaking  an  advancement  of  this  muscle  within  a 
few  days  after  the  tenotomy.  The  only  course  that  can  be  pursued  is  i;o 
introduce  the  counteracting  suture.  An  advancement  according 
to  exact  rules  is  extraordinarily  difficult,  as  the  muscle  can  often  be 
scarcely  found  in  the  congested  and  somewhat  swollen  tissue,  and  the 
procedure  in  addition  is  painful  to  the  patient  in  spite  of  the  cocain- 


THE  EYE-MUSCLES.  IOI 

injection.  Under  these  circumstances  if  the  suture  has  not  had  the 
desired  effect,  it  is  much  better  to  wait  until  the  eye  has  recovered  from 
its  congested  condition,  and  several  weeks  later  undertake  the  advance- 
ment. An  unsuccessful  attempt  at  advancement  may  render  the  con- 
dition even  worse. 

Among  the  unpleasant  sequelae  that  may  follow  a  tenotomy  are 
widening  of  the  palpebral  fissure,  protrusion  of  the  eye  and 
retraction  of  the  caruncle.  The  last  may  occasionally  be  observed 
immediately  after  the  performance  of  the  tenotomy,  and  is  due  to 
fibers  which  pass  from  the  rectus  internus  to  the  caruncle;  these  fibers 
become  stretched  through  retraction  of  the  muscle,  thus  exerting  a 
traction  on  the  caruncle,  and  causing  its  depression.  Under  these 
circumstances,  the  fibers  should  be  divided  by  undermining  the  con- 
junctiva toward  the  caruncle  with  small  clips  of  the  scissors.  This  can 
also  be  done  some  time  after  the  tenotomy,  through  a  freshly  made 
opening  in  the  conjunctiva.  An  abnormal  widening  of  the  palpebral 
fissure  should  be  remedied  by  tarsorrhaphy. 

The  principal  indication  for  advancement  of  the  rectus  internus 
is  manifest  divergent  squint,  but  it  must  also  be  performed  in  exophoria, 
in  which  asthenopic  symptoms,  such  as  fatigue  and  variable  diplopia, 
arise  even  during  use  of  the  eyes  at  distance,  provided,  of  course,  that 
these  symptoms  cannot  be  remedied  by  the  use  of  prisms.  As  the 
extreme  correction  possible  from  an  advancement  of  the  rectus  internus 
is  about  12  degrees,  the  operator  must  be  governed  in  using  this  opera- 
tion by  the  degree  of  exophoria.  If  the  heterophoria  is  slight,  the 
operation  should  be  confined  to  a  simple  advancement  without  excision, 
or  with  excision  of  a  short  piece  of  the  muscle.  It  is  desirable  that  the 
patient  should  show  immediately  after  the  operation  a  slight  conver- 
gence when  looking  into  the  distance.  If  binocular  vision  existed  before 
the  operation,  the  convergence  will  soon  disappear  under  the  influence 
of  the  fusion-tendency.  When  a  carefully  performed  advancement  of 
one  internus  does  not  relieve  the  patient  of  the  exophoria  and  its 
accompanying  symptoms,  a  similar  advancement  of  the  rectus  internus 
of  the  other  eye  may  be  undertaken  after  the  lapse  of  a  few  weeks. 

In  paralytic  squint,  operative  interference  should  be  resorted  to 
only  if  it  is  decided  that  the  paralysis  is  permanent  and  has  been 
present  for  at  least  nine  to  twelve  months.  An  effect  upon  the 
mobility  of  the  eye  can  be  promised  from  the  advancement  only  in 
cases  of  partial  paralysis  of  the  muscle.  In  total  paralysis  no  influence 


102  OPHTHALMIC    SURGERY. 

can  be  exerted  on  the  motility,  and  the  operation  is  performed  rather 
with  the  idea  of  returning  the  paralyzed  eye 'to  its  normal  position. 

In  general,  all  strabismus-operations  have  only  a  cosmetic  value. 
It  is  only  in  rare  cases  that  the  operation  for  associated  strabismus, 
restores  binocular  vision. 

To  secure  a  sufficiently  good  cosmetic  result,  the  co-operation  of  the 
patient  is  needed  not  only  during  the  operation  (by  remaining  quiet, 
etc.),  but  also  immediately  afterward,  when  a  rapid  examination  of 
the  eye  must  be  made  in  order  to  alter  the  effect  if  necessary,  by  means 
of  supplementary  procedures  (sutures,  etc.).  It  is  better,  therefore,  to 
undertake  the  operation  only  in  those  patients  who  possess  the  neces- 
sary average  intelligence  for  the  different  tasks  assigned  to  them. 
Therefore,  in  our  clinic  we  operate  only  on  children  who  have 
passed  their  twelfth  or  thirteenth  year.  Before  this  period  we 
confine  ourselves  to  an  accurate  correction  of  refraction  with  the  aid  of 
atropin,  to  the  constant  use  of  glasses,  and  to  the  continuous  exercise 
of  the  squinting  eye  by  systematic  bandaging  of  the  healthy  eye.  When 
indicated,  resort  is  made  to  regulated  stereoscopic  practice. 


CHAPTER  IX. 

ENUCLEATION  OF  THE  EYEBALL  AND  ITS  SUB- 
STITUTES. 

ENUCLEATION. 

The  greater  number  of  the  enucleations  of  the  eyeball  are  made  under 
general  anesthesia.  If,  however,  the  eye  is  not  markedly  injected  or 
tender  to  pressure,  the  operation  may  be  performed  under  cocain- 
anesthesia.  In  the  latter  case  one  first  thoroughly  anesthetizes  the 
conjunctival  sac  by  instilling  a  3  per  cent,  solution  of  cocain.  The 
anesthesia  may  be  better  completed  by  adding  several  drops  of  adrena- 
lin solution,  which  produces  pallor  of  the  eye  and  anemia  of  the 
conjunctiva. 

The  first  step  of  the  operation  is  to  separate  the  conjunctiva  from 
the  eyeball.  A  fold  of  the  bulbar  conjunctiva  is  picked  up  with  a  pair 
of  toothed  forceps  in  the  horizontal  meridian  near  the  limbus,  and  a 
small  incision  is  made  into  it  close  to  the  limbus.  Not  a  particle  of 
conjunctiva  should  remain  on  the  bulb,  as  every  millimeter  is  of  the 
greatest  importance  for  the  wearing  of  a  prothesis. 

The  detachment  of  the  conjunctiva  is  best  performed  in  the 
following  manner  (Fig.  51):  The  blunt  blade  of  the  small,  slightly 
curved  scissors  is  inserted  into  the  opening  made  near  the  limbus,  and 
pushed  forward  beneath  the  neighboring  conjunctiva,  while  the  other 
blade  remains  in  front  of  the  cornea.  The  blades  must  be  held  parallel 
to  the  limbus.  The  scissors  are  then  closed,  thus  separating  the  con- 
junctiva from  its  attachment  at  the  limbus.  This  is  continued,  the 
conjunctiva  being  picked  up  with  forceps  at  the  end  of  the  incision  and 
the  scissors  being  pushed  forward  until  the  conjunctiva  is  loosened 
completely  at  the  limbus.  As  a  right-handed  operator  always  cuts  from 
right  to  left,  the  detachment  of  the  conjunctiva  in  the  case  of  the  right 
eye  should  begin  on  the  inner  side;  in  the  case  of  the  left  eye, 'on  the 
outer  side  of  the  corneal  limbus.  The  lower  periphery  is  separated 
first,  and  then  the  upper,  so  as  not  to  be  disturbed  by  the  blood  con- 
stantly running  down.  After  the  conjunctiva  has  been  cut  all  the  way 
around,  it  is  undermined  with  closed  scissors  on  all  sides,  in  order  to 
completely  detach  it  from  the  eyeball. 


104 


OPHTHALMIC    SURGERY. 


The  division  of  the  straight  eye-muscles  is  then  made.  The 
tendon  of  the  internal  rectus  is  the  first  muscle  to  be  divided  on  the  right 
eye;  the  tendon  of  the  external  rectus,  on  the  left  eye.  The  tendon  is 
picked  up  with  the  toothed  forceps  in  exactly  the  same  manner  as 
described  under  tenotomy  (p.  84).  While  the  assistant  slightly  lifts 
the  conjunctiva  in  front  of  the  muscle,  the  operator,  having  scissors 
ready  in  his  right  hand,  puslies  the  shut  forceps  held  in  his  left  hand, 
along  the  sclera  back,  close  to  the  attachment  of  the  muscle,  where 


FIG.  51. — Enucleation  of  the  right  eye.  Division  of  the  conjunctiva  has  advanced 
to  the  vertical  meridian.  Note  the  position  of  the  scissors:  one  of  its  blades  is  pushed 
forward  beneath  the  conjunctiva,  the  forceps  at  the  same  time  lifting  the  margin  of  the 
conjunctival  wound  somewhat;  the  other  blade  of  the  opened  scissors  is  placed  in  front  of 
the  cornea  in  such  a  manner  that  by  shutting  the  instrument  the  conjunctiva  is  separated 
close  to  the  limbus. 


he  opens  it  and  grasps  the  muscle  by  pressing  the  forceps  against  the 
sclera.  The  final  detachment  of  the  tendon  from  the  sclera  is  not  com- 
pleted as  in  tenotomy;  but  the  muscle  is  cut  through  at  the  side  of  the 
forceps,  away  from  the  eyeball,  by  pushing  the  blunt  blade  of  the 
scissors  under  the  muscle-tendon  from  beneath  and  cutting  through  it 
obliquely,  so  that  a  short  piece  remains  attached  to  the  eye,  by  which 
the  globe  is  held  during  the  subsequent  stages  of  the  operation  (Fig.  52). 
By  the  tenotomy,  Tenon's  capsule  is  laid  open,  completely  exposing 
the  sclera.  The  small,  slightly  curved  scissors,  employed  for  the 


EXUCLEATION  OF  THE  EYEBALL.  105 

division  of  the  conjunctiva  and  the  tendon,  are  now  replaced  by  a  some- 
what larger  and  stronger  pair,  which  may  be  either  straight  or  slightly 
curved,  the  enucleation-scissors. 

The  eyeball,  which  is  held  throughout  by  the  stump  of  the  muscle- 
tendon,  is  rotated  in  a  horizontal  direction  toward  the  side  opposite 
the  cut  muscle  (i.  e.  the  right  eye  outward,  and  the  left  eye  inward  i, 
and  the  scissors  inserted  into  the  opening  in  Tenon's  capsule, 
which  is  found  best  by  pressing  the  blunt  blade  of  the  opened  scissors 


!•'!<;.   ;2. — The-  forceps  have  grasped  ilu1  internal  rc<  iu>  at  its  attachment,  and  have  turned 


the  eve  outward;  one  blade  of  the  scissors  is  pushed  under  the  niu-cle  to  the  inner  side  ol 


ut  through  it  verticallv  to  the  tin 


against  the  bared  sclera  and  pushing  it  from  here  upward  under  the 
capsule.  In  this  way  the  blade  glides  under  the  tendon  of  the  superior 
rectus  (Fig.  53).  The  muscle  i-  recogni/ed  by  the  marked  resis- 
tance which  it  offers  the  scissors.  The  eyeball  i-  next  pressed  forward 
with  the  aid  of  the  scissors,  so  that  the  tendon  of  the  muscle  is  exposed, 
when  it  is  cut  off  close  to  its  in.-crlion  with  one  snip  of  the  scissors. 
The  tendon  of  the  inferior  rectus  is  next  severed  by  similar  fixation 
and  position  of  the  eyeball,  excepting  that  the  operating  hand  must  be 


io6 


OPHTHALMIC    SURGERY. 


held  perpendicularly.  In  the  same  manner  as  before,  the  blunt  blade 
of  the  scissors  glides  beneath  the  capsule  of  Tenon,  lifts  up  the  tendon 
of  the  inferior  rectus,  so  it  can  be  seen  on  the  scissors,  and  cuts  through 
it. 

The  tendon  of  the  fourth  straight  eye-muscle  is  not  divided  until 
after  the  severance  of  the  optic  nerve.  While  the  eyeball  is  held 
rotated  to  the  right,  the  closed  enucleation-scissors  are  pushed  along 
the  sclera  slowly  to  the  posterior  pole  of  the  eye  (Fig.  54).  Inasmuch 
as  the  optic  nerve  of  the  right  eye  is  approached  from  the  inner  side,  it 
is  more  easily  reached  than  the  left  eye,  where  the  advance  is  made 


FIG.  53. — The  forceps  pull  the  eye  downward  with  the  tendinous  stump  of  the  rectus 
internus,  while  the  blunt  blade  of  the  enucleation-scissors  is  pushed  from  the  inner  side 
under  Tenon's  capsule,  until  it  reaches  the  superior  rectus,  which  it  now  cut  off  close  to  its 
insertion. 

from  the  outer  side,  and  consequently  the  posterior  pole  must  be  passed 
before  the  nasal  side  of  the  bulb  is  reached.  The  beginner  often  has 
difficulty  in  locating  the  optic  nerve.  If  the  eyeball  is  rotated  about 
its  vertical  axis  to  the  right,  and  the  closed  scissors  held  to  the  horizon- 
tal meridian  against  the  sclera,  and  moved  from  above  downward,  the 
optic  nerve  can  be  made  out  as  a  tightly  stretched  cord.  The  finding 
of  the  optic  nerve  may  be  facilitated  by  drawing  the  eye  slightly  out  of 
the  orbit  in  order  to  stretch  the  nerve.  Ordinarily  the  nerve  should 
be  severed  close  to  the  bulb.  After  having  ascertained  its  position,  the 
scissors  are  opened,  the  operator  feels  around  once  more  to  make  sure 
that  the  nerve  is  between  the  two  blades,  and  then  divides  it  with  one 


ENUCLEATIOX  OF  THE  EYEBALL. 


IOJ 


cut.  The  loosened  bulb  is  immediately  pressed  forward  with  the  closed 
scissors,  and  turned  out  from  the  orbit  so  that  the  assistant  may  check 
the  bleeding  with  a  tampon  and  prevent  any  suffusion  into  the  orbit. 
Nothing  remains  now  except  to  free  the  bulb  from  its  remaining 
attachments,  which  consist  of  the  tendons  of  both  oblique  muscles 
and  of  the  fourth  rectus,  and  these  are  cut  through  with  the  scissors 
close  to  the  bulb.  If  the  enucleation  has  been  properly  performed,  no 
large  tissue-remnants  should  remain  on  the  eyeball  with  the  exception 
of  the  stump,  by  which  the  bulb  is  held.  The  wound  in  the  conjunctiva 


FIG.  =54. — The  eye,  which  is  still  held  fast  at  the  same  point,  is  strongly  turned  outward 
exactly  around  its  vertical  meridian.  The  opened  enucleation-scissors  have  the  optic 
nerve  between  their  blades  ready  to  cut  through  it. 

may  be  closed  either  with  a  purse-string  suture  or  with  several  vertical 
sutures.  If  the  latter  are  employed,  it  is  important  to  draw  both, 
threads  through  near  the  border  of  the  wound,  so  that  no  shortening 
of  the  conjunctival  sac  may  be  produced  by  the  central  margin  of  the 
conjunctiva  projecting  inward  in  the  form  of  a  roll.  It  is,  however, 
not  at  all  necessary  to  close  the  conjunctiva  with  sutures.  It 
will,  of  itself,  assume  the  best  and  most  suitable  position,  and  the 
wound  will  heal  in  a  few  days.  Moderate  compression  should  be 
employed  in  the  dressing  in  order  to  prevent  secondary  hemorrhage. 
On  the  day  after  the  operation  the  bandage  is  changed  and  a  light  pad 
worn  for  several  days.  The  conjuntival  sac  is  cleansed  with  a  weak 
bichlorid  solution. 

If  the  operation  is  performed  under  cocain-anesthesia,  the  .s  per 
cent,  solution  is  instilled  into  the  conjunctival  sac,  and  a  i  per  cent. 


I08  OPHTHALMIC    SURGERY. 

solution  (i  c.c.)  injected  beneath  the  conjunctiva  by  means  of  a  syringe. 
The  latter  is  inserted  four  times  at  the  outer,  inner,  upper  and  lower 
portions.  The  conjunctiva  is  thus  raised  up  in  the  form  of  a  large 
bleb.  The  cutting  may  then  be  made  without  pain.  Next  follows  a 
thorough  undermining  of  the  conjunctiva,  in  order  that  it  may  not  inter- 
fere later  during  the  removal  of  the  eye.  The  muscle-tendons  are  then 
anesthetized  by  injecting  ^  c.c.  of  a  i  per  cent,  cocain-solution  beneath 
the  capsule  of  Tenon,  immediately  above  each  tendon.  The  point  of 
the  needle  is  placed  in  the  direction  of  the  muscle,  and  pressed  close 
against  the  sclera.  This  produces  a  bleb-like  bulging  forward  of  Ten- 
on's capsule,  similar  to  that  previously  noticed  in  the  conjunctiva. 
After  lightly  massaging  the  tissues,  the  division  of  the  muscles  should 
be  proceeded  with.  To  further  lessen  the  possibility  of  pain,  the  mus- 
cle-tendons may  be  picked  up  with  a  strabismus-hook  before  parting 
them,  and  it  is  advisable  at  this  time  to  cut  off  the  fourth  rectus  so  that 
the  eye  may  be  absolutely  free  as  soon  as  the  optic  nerve  has  been  severed. 

The  third  injection  is  made  into  the  neighborhood  of  the  optic  nerve 
after  the  division  of  the  muscle-tendons.  The  syringe,  containing  a  i 
per  cent,  solution  of  cocain,  to  which  y1^-  c.c.  adrenalin  has  been  added, 
is  again  used,  and  the  solution  slowly  injected  into  the  tissues  about  the 
nerve.  After  waiting  for  about  one  minute  the  optic  nerve  may  be 
divided  in  the  usual  manner.  It  is  not  necessary  that  the  syringe  have  a 
curved  needle,  as  the  nerve  can  be  approached  with  a  straight  needle 
just  as  well. 

Complications. — The  enucleation  does  not  always  proceed  as 
smoothly  as  described,  and  especially  for  the  beginner  is  it  no  easy 
operation.  Difficulties  may  be  encountered  even  during  the  incision 
into  the  conjunctiva.  If  the  eye  had  been  inflammed  for  a  long  time, 
adhesions  frequently  exist  between  the  conjunctiva  and  the  sclera, 
and  the  separation  may  be  troublesome.  This  is  particularly  the  case 
if  subconjunctival  injections  of  solutions  of  mercuric  chlorid  or 
sodium  chlorid  have  been  repeatedly  made,  or,  after  injuries,  destruc- 
tive processes  have  led  to  cicatricial  fusion  between  conjunctiva  and 
sclera.  The  loosening  of  the  conjunctiva  becomes  most  difficult, 
sometimes  even  impossible,  after  the  action  of  corrosives  when,  in  place 
of  a  membrane,  only  a  small  layer  of  scar-tissue  is  found,  which  is  thin 
and  easily  perforated.  In  any  case  the  first  consideration  is  to  pre- 
serve the  conjunctiva  as  much  as  possible,  and  not  to  tear  it  by  unneces- 
sary handling  with  the  toothed  forceps.  The  severing  of  the  muscles 


ENUCLEATION  OF  THE  EYEBALL.  1 09 

is  made  easier  for  the  beginner  if  he  searches  for  them  with  the  strabis- 
mus-hook. The  operator,  however,  who  pushes  the  scissors  beneath 
Tenon's  capsule,  after  the  manner  described,  finds  that  this  method 
has  the  advantage  of  greater  rapidity,  but  he  must  be  careful  while 
cutting  the  tendons  of  the  superior  and  inferior  recti  not  to  injure  the 
lid  by  a  snip  of  the  scissors.  During  the  entire  operation  the  lids 
must  be  held  apart  by  a  lid-speculum.  By  using  Desmarres'  lid- 
retractors  an  assistant  is  spared. 

Should  the  muscle-stump,  by  means  of  which  the  eyeball  is  handled, 
break  or  tear  off  from  repeated  seizures  with  forceps  new  difficulties 
arise.  If  such  an  eye  is  soft,  it  is  best  to  simply  pick  up  a  fold  of  the 
sclera  in  this  neighborhood  and  in  this  way  hold  the  eyeball  or,  when 
possible,  grasp  it  by  the  remnants  of  the  tendon  of  another  muscle. 
When,  however,  they  have  been  cut  off  perfectly  smooth,  the  index  and 
middle  fingers  of  the  left  hand  must  be  used  to  hold  the  bulb  in  the 
desired  position  in  order  to  cut  through  the  nerve.  The  closer  to  the 
eyeball  the  tendon  is  grasped  and  the  less  frequently  the  forceps  are 
applied,  the  more  firmly  will  the  tendon  hold. 

The  most  difficult  part  of  the  operation  for  the  beginner  is  the 
division  of  the  optic  nerve.  If  the  knowledge  of  its  position  is 
acquired  by  slow  groping  about  with  the  closed  scissors,  it  will  be 
almost  impossible  to  miss  it,  but  should  the  eye  be  incl,ned  in  an  oblique 
direction,  and  the  operator  hastily  make  a  cut  anywhere  backward  in 
the  orbit,  he  will  not  succeed  in  dividing  the  nerve.  This  blind  cutting 
leads  to  a  profuse  hemorrhage  into  the  orbit,  which  cannot  be  stopped 
by  inserting  a  tampon,  as  long  as  the  bulb  remains  in  place.  The  infil- 
tration may  become  so  extensive  that  the  tissue  of  the  orbit  is  bulged 
forward  like  a  tumor,  and  weeks  may  elapse  before  the  blood  will 
become  absorbed.  An  attempt  should  be  made  to  cut  the  optic  nerve 
with  the  first  stroke.  Injury  to  the  levator  palpebrse  can  only  occur, 
if  the  position  in  which  the  eyeball  is  held  or  the  direction  of  the  cutting, 
are  extremely  faulty.  Cases  of  total  ptosis,  however,  have  been  reported 
after  enucleation. 

After  division  of  the  optic  nerve  the  eyeball  must  at  once  be  displaced 
forward,  so  that  the  tampon  may  be  inserted.  It  is  unpleasant  if 
the  operator,  instead  of  severing  the  nerve,  cuts  into  the  posterior  part 
of  the  bulb  itself.  This  may  happen,  if  the  eyeball  is  soft,  following 
severe  injuries  which  have  induced  a  complete  collapse  of  the  bulb,  or 
if  the  globe  has  ruptured  when  the  muscles  were  severed.  It  is  then 


110  OPHTHALMIC    SURGERY. 

necessary  to  search  for  the  nerve,  while  still  holding  the  stump  of  the 
bulb,  and  resect  it.  As  the  surrounding  orbital  tissue  becomes  much 
swollen  from  effusion  of  blood,  it  is  difficult  to  dissect  and  free  the  optic 
nerve  so  as  to  divide  it  further  back.  The  bearings  to  its  position  are 
lost,  and  the  profuse  bleeding  prevents  a  clear  view. 

Resection  of  the  optic  nerve  must  also  be  done,  if,  during 
enucleation  because  of  a  malignant  growth,  the  stump  of  the  nerve  is 
found  involved  by  the  tumor.  The  nerve  should  be  cut  as  far  back  of 
the  bulb  as  possible;  but  if  it  is  assuredly  affected,  exenteration  of 
the  orbit  (p.  113)  is  a  safer  procedure  than  resection  of  the  nerve.  In 
iridocyclitis  following  injuries,  in  which  sympathetic  inflammation 
threatens,  as  much  of  the  nerve  as  possible  should  be  resected. 

A  rare  complication  after  division  of  the  optic  nerve  is  severe,  almost 
uncontrollable  hemorrhage  (arteriosclerosis,  hemophilia).  If  ener- 
getic compression  does  not  suffice  to  check  the  bleeding,  ligation  of 
the  blood-vessels  must  be  resorted  to,  or  even  the  Paquelin  cautery. 

The  main  indications  for  enucleation  are: 

1.  When  the  visual  power  of  the  eye  is  irretrievably  lost,  and  the  eye 
itself  gives  the  patient  pain. 

2.  When  the  sound  eye  is  seriously  endangered  by  a  sympathetic 
affection. 

3.  Malignant  intraocular  tumors. 

Therefore,  every  painful  amaurotic  eye  may  be  enucleated.  Enuclea- 
tion of  still  functionating  eyes  must  also  be  resorted  to,  as  for  example, 
when  there  is  an  intraocular  tumor.  If  after  an  injury,  an  iridocyclitis 
develops  and  the  outbreak  of  a  sympathetic  inflammation  is  feared,  we 
do  not  have  recourse  to  enucleation,  so  long  as  the  eye  retains  good 
light-perception  at  six  meters  and  has  the  proper  light-projection.  How- 
ever, if  both  light-perception  and  projection  have  become  greatly 
reduced,  the  enucleation  must  not  be  delayed,  as  we  now  have  proof 
positive  that  the  structures  of  the  eye  upon  which  the  sight  depends  are 
becoming  involved  in  the  inflammatory  process,  and  that  the  visual 
power  is  being  destroyed  for  ever.  After  recent  injuries,  enucleation 
should  not  be  deferred  when  there  is  no  doubt  that  vision  is  lost. 
Extensive  ruptures  of  the  cornea  and  sclera  with  prolapse  of  the  iris 
and  crystalline  lens  justify  immediate  removal  of  the  globe.  Prompt 
action  spares  the  patient  weeks  and  months  of  suffering.  After  great 
injuries  one  may  suture  the  gaping  wound  before  the  enucleation,  so 
as  to  make  a  squeezing-out  of  the  ocular  contents  impossible. 


ENUCLEATION  OF  THE  EYEBALL.  Ill 

Ruptures  of  the  sdera  furnish  the  indication  forenucleation  much  less 
frequently.  Even  though  the  visual  power  is  usually  either  entirely  ruined 
or  returns  only  to  a  minimum  extent,  still  such  eyes  can  later  become 
absolutely  quiescent,  and  often  do  not  seem  to  be  materially  disfigured. 
Not  until  the  rupture  of  the  sclera  is  followed  by  a  shrinking  of  the 
globe,  and  this  being  eventually  associated  with  pain  and  injection, 
should  enucleation  be  performed,  but  then,  however,  without  delay. 
Justification  for  enucleation  must  not  be  considered  as  existing  simply 
because  the  light-perception  of  the  eye  is  completely  destroyed  after  a 
trauma.  Not  infrequently  it  happens,  that  immediately  after  a  blunt 
trauma  the  light-perception  is  completely  lost,  but  both  perception  and 
projection  return  gradually  and  within  a  certain  time  may  even  reach 
normal.  We  have  seen  such  eyes,  which,  from  a  condition  of  absolute 
amaurosis,  (rupture  of  the  sclera,  with  hemorrhage  and  obscuration 
of  the  lens)  have  regained  partial  visual  acuity. 

Enucleation  is  practised  on  eyeballs  with  a  high  degree  of  ectasia 
(total  staphyloma  of  the  cornea,  and  staphyloma  of  the  sclera),  which  are 
disfiguring  because  of  their  size,  and  are  in  danger  of  rupture,  resulting 
in  serious  hemorrhage.  Enucleation  is  indicated  when  panophthalmi- 
tis  is  developing.  For  example,  if,  after  an  injury  which  in  itself  was 
not  considered  sufficient  indication  to  perform  an  enucleation,  the  eyeball 
becomes  infected,  and  this  infection  is  rapidly  progressive  and  through 
its  intensity  makes  a  panophthalmitis  probable,  we  check  the  process 
by  enucleation  of  the  eyeball.  Enucleation  is  also  demanded  if  the  eye 
becomes  seriously  infected  after  operative  interference,  as,  for  instance, 
a  cataract-operation.  If,  however,  the  panophthalmitis  has  already 
developed,  that  is,  if  exophthalmos,  marked  edema  of  the  lids,  limita- 
tions of  the  movements  of  the  eyeball,  chemosis,  etc.,  are  already 
present,  enucleation  is  contraindicated,  as  experience  has  shown  repeat- 
edly that  meningitis  may  follow  the  operation.  The  proper  procedure 
in  such  cases  is  to  open  the  anterior  portion  of  the  eyeball  to  permit  the 
free  drainage  of  the  pus  and  thus  furnish  the  patient  relief. 

EVISCERATION  OF  THE  EYEBALL. 

Evisceration  of  the  bulb  with  sewing  in  of  glass  balls  or  gold  balls, 
etc.  (Mules's  operation)  is  not  performed  at  our  clinic.  Cases  of 
sympathetic  inflammation  have  repeatedly  been  observed  after  this 
operation,  not  only  by  us,  but  also  by  others.  The  expulsion  of  the 
sewed-in  balls  occurs  frequently,  and  sometimes  even  after  years  have 


112  OPHTHALMIC    SURGERY. 

passed.  This  may  be  accompanied  by  symptoms  of  inflammation, 
which  may  require  operative  interference,  such  as  the  shelling  out  of 
the  balls;  in  fact,  subsequent  enucleation  of  the  stump  may  be  necessary. 

OPTICO-CILIARY  NEUROTOMY. 

Optico-ciliary  neurotomy  is  a  substiute  operation  for  enucleation 
of  the  bulb.  If  an  eye  blinded  by  glaucoma  has  become  painful,  a 
certain  indication  for  enucleation  exists.  But  in  case  this  eye  is  not 
disfiguring,  it  is  more  desirable  that  the  owner  retain  it  than  replace  it 
with  an  artificial  eye,  the  use  of  which  is  associated  with  many  incon- 
veniences. Such  eyes,  therefore,  furnish  the  suitable  indication  for 
optico-ciliary  neurotomy.  Rarely  do  we  use  it  if  the  eye  has  become 
blind  through  a  spontaneous  irido-cyclitis — one  not  induced  by  injury— 
and  causing  the  patient  pain.  In  these  cases  the  eyes  for  the  most  part 
are  shrunken  and  disfiguring,  so  that  enucleation  must  be  recommended 
on  cosmetic  grounds  alone.  If  an  injury  has  preceded,  enucleation 
must  of  necessity  be  performed,  as  an  optico-ciliary  neurotomy  would 
not  prevent  a  sympathetic  inflammation.  When  the  slightest  suspicion 
of  an  intraocular  tumor  exists,  that  enucleation  is  peremptory  in  every 
case,  needs  no  further  explanation. 

The  operation  is  done  under  general  anesthesia.  It  is  begun  by 
freeing  the  rectus  internus  if  in  the  right  eye  and  the  rectus  externus  if  in 
the  left  eye,  as  in  an  operation  for  advancement.  A  suture  is  passed 
through  the  muscle  at  a  distance  of  about  f  cm.  from  its  attachment, 
then  tied,  and  given  to  the  assistant  to  hold,  after  which  the  muscle  is 
divided  between  its  insertion  and  the  knot.  The  assistant  now  pulls 
the  muscle  away  from  the  eye  by  means  of  the  suture,  the  operator 
using  the  stump,  which  remains  attached  to  the  eye,  to  fix  the  bulb. 
As  in  enucleation,  we  now  pass  slowly  backward  along  the  sclera  with 
the  enucleation-scissors,  and  feel  around  for  the  optic  nerve,  take  it 
between  the  two  blades  of  the  scissors  and  glide  backward  along  it  for 
a  short  distance.  With  one  vigorous  snip  it  is  divided.  The  scissors 
are  withdrawn  at  once  and  strong  pressure  maintained  on  the  bulb 
through  the  closed  lids  for  five  minutes  to  prevent  a  hemorrhage  into 
the  orbit.  Without  this  compression  it  may  happen,  that  the  loose  eye  is 
pushed  through  the  palpebral  fissure  at  once,  or  it  may  be  found  out  of 
the  orbit  on  the  next  day.  As  a  reposition  is  impossible,  nothing 
remains  but  enucleation.  But  this  complication  may  also  occur  in 
spite  of  a  perfect  compression,  as  in  the  aged,  who  chiefly  undergo  this 


ENUCLEATION  OF  THE  EYEBALL.  113 

operation,  arteriosclerosis  may  be  the  cause  of  such  an  extensive 
hemorrhage. 

As  it  is  obvious  that  we  have  not  divided  all  the  ciliary  nerves 
(transmitters  of  the  pain)  with  the  one  cut,  we  now  turn  the  eye  about 
its  vertical  axis  in  such  a  manner,  that  the  posterior  surface  of  the 
eyeball  lies  free  in  the  palpebral  fissure,  and  are  thus  enabled  to  readily 
cut  the  ciliary  nerves  that  pass  through  the  sclera  in  the  neighborhood 
of  the  optic  nerve,  the  greater  number  of  which  have  already  been 
torn  during  the  turning  of  the  eyeball.  If  a  long  piece  of  the  optic 
nerve  remains  attached  on  the  eyeball,  a  part  of  it  may  be  resected 
(neurectomy).  After  this  the  eyeball  is  replaced  in  its  normal  position, 
and  the  muscle  carefully  sutured  to  the  stump  to  insure  its  normal  mo- 
tility.  After  sewing  the  conjunctiva,  a  firm  pressure-bandage  is 
applied  over  the  closed  lids.  Usually,  healing  progresses  without  inci- 
dent. The  slight  amount  of  exophthalmos  after  the  operation,  because 
of  the  hemorrhage,  disappears  within  a  short  time. 

If  the  operation  has  been  performed  according  to  these  directions,  the 
cornea  is  perfectly  anesthetic  and  the  eyeball  free  from  pain.  The 
sensitiveness  of  the  cornea  returns  very  slowly.  A  neuroparalytic 
keratitis  is  not  to  be  feared.  Over  the  fundus  the  blood-vessels  are  seen 
to  be  absolutely  empty,  appearing  as  white  lines,  and  the  papilla  is  a 
pure  white.  The  tension  of  the  bulb  remains  normal,  sometimes  even 
greater  than  normal.  Atrophy  of  the  eyeball  does  not  develop. 

EXENTERATION  OF  THE  ORBITAL  CAVITY. 

Exenteratio  orbitce,  the  removal  of  all  the  contents  of  the  orbit  for  the 
extirpation  of  malignant  neoplasms,  whether  of  the  orbit  itself  or 
of  the  eyeball  after  they  have  broken  through  the  sclera,  is  performed 
as  follows: 

If  the  lids  are  to  be  preserved,  the  palpebral  fissure  must  first  be 
widened  by  canthotomy ;  this  exposes  the  outer  border  of  the  orbit. 
Next,  the  conjunctiva  of  the  lower  fornix  is  cut  through  with  a  sharp 
scalpel  to  the  bony  lowrer  border  of  the  orbit,  which  is  thus  completely 
bared.  The  assistant  draws  the  lid  away  with  a  dull  tenaculum. 
The  upper  conjunctival  fornix  is  then  cut  through  in  the  same  manner, 
along  the  upper  orbital  margin.  To  the  inner  side  both  incisions  meet 
at  the  front  part  of  the  lachrymal  bone.  Both  lids  can  now  be  easily 
drawn  away  from  each  other  with  tenacula,  so  that  the  entire  orbital 
border  is  exposed.  The  periosteum  is  incised  along  the  bony  margin 


114  OPHTHALMIC    SURGERY. 

of  the  orbit,  and  by  means  of  a  periosteal  elevator  or  a  closed,  somewhat 
curved,  scissors,  pushed  between  bone  and  periosteum,  the  entire 
contents  of  the  orbit  are  shelled  out  with  great  rapidity  on  all  sides  to 
the  posterior  end  of  the  orbit.  Only  at  the  inferior  orbital  fissure  and  at 
the  posterior  crest  need  we  make  use  of  the  scissors  to  divide  the  fascial 
strands.  With  proper  care  we  can  easily  avoid  injuring  the  thin  bones 
of  the  orbit.  Finally  the  entire  mass  is  divided  as  far  back  as  possible 
by  several  snips  of  the  scissors.  Energetic  tamponing  prevents  serious 
hemorrhage,  for  the  checking  of  which  we  are  rarely  forced  to  use  the 
cautery.  The  orbital  cavity  is  now  tightly  packed,  gauze  is  pushed 
beneath  the  lids  so  that  they  will  not  fall  into  the  orbit,  and  a  pressure- 
dressing  applied.  At  the  outset  a  long  time  ensues  before  the  wound 
of  the  orbit  begins  to  be  covered  with  granulations,  and  several  weeks 
pass  before  the  entire  cavity  has  become  filled  with  granulations. 
During  this  time  it  must  be  kept  loosely  packed. 

In  the  end,  however,  the  lid  is  always  drawn  far  back  by  scar-tissue, 
and  the  use  of  an  artificial  eye  is  not  possible.  The  palpebral  conjunc- 
tiva may  even  become  a  burden  to  the  patient  on  account  of  its  secretion 
and,  therefore,  nothing  is  lost,  if  in  the  exenteration  of  the  orbit  the 
lids  are  also  cut  out.  Such  an  operation  is  easier,  and  the  large  wound 
in  the  skin  can  be  so  diminished  by  a  few  vertical  sutures  that  only 
the  normal  width  of  the  palpebral  fissure  remains. 


CHAPTER  X. 

PLASTIC    OPERATIONS   WITH    PEDICLED    FLAPS 
ON    THE    EYELIDS. 

Plastic  operations  with  pedicled  flaps  are  particularly  adapted  to 
those  cases  in  which  a  lid  affected  with  a  neoplasm  must  be  excised. 

As  long  as  a  new-growth  in  the  lids  has  merely  involved  the  skin,  and 
the  tarsus  is  wholly  preserved,  the  plastic  operation  with  a  pedicled  flap 
from  the  surrounding  tissue  differs  in  no  respect  from  the  identical 
operation  in  other  regions  of  the  body. 

The  method  of  Fricke  is  used  in  case  of  an  extensive  skin-defect 
(d)  in  either  the  upper  or  lower  lid.  A  flap  is  taken  from  the  neighbor- 
ing skin,  as  is  shown  in  the  illustration  (Fig.  55)  and  the  base  joined  to 
the  defect  in  the  tissue.  Because  of  possible  retraction  of  the  skin 
after  it  has  been  dissected  free,  the  flap  (/)  must  be  cut  about  one-third 
larger  than  the  area  to  be  covered,  and  the  base  wide  enough  to  insure 
perfect  nutrition.  For  the  same  purpose,  rotation  of  the  flap  should 
be  made  as  easy  as  possible  by  an  adequate  undermining  of  the  under- 
lying tissues.  The  flap,  which  now  covers  the  excised  area,  is  held  in 
its  new  position  by  sutures.  The  opening,  caused  by  the  removal  of 
the  flap,  is  dissected  sufficiently  back  of  the  margins,  and  the  skin- 
edges  brought  together,  at  least  in  part,  by  sutures,  the  remainder  being  „ 
left  to  heal  by  granulation;  or  the  wound  is  covered  by  transplanting 
epidermis,  according  to  the  method  of  Thiersch,  or  by  a  small  non- 
pedicled  flap.  The  bulging  at  the  base  of  the  flap  produced  by  the 
necessary  rotation  soon  disappears,  so  that  no  subsequent  disfigurement 
exists. 

If,  however,  the  margin  of  the  lid  has  already  been  involved,  as  is 
usually  the  case,  since  new-growths  spring  more  particularly  from  the 
lid-margin,  the  restoration  of  the  lid  becomes  a  more  difficult  matter. 

The  method  of  Dieffenbach  is  the  typical  one  for  the  lower  lid. 
As  a  recurrence  of  a  lid-neoplasm  is  only  prevented  by  cutting  at  least  a 
full  half-centimeter  away  from  the  growth,  a  large  part  of  the  lid  must 
be  sacrificed  even  if  the  tumor  is  not  extensive,  and,  if  large,the  whole 
lid  must  be  excised.  There  is  very  little  advantage  in  retaining  the 


u6 


OPHTHALMIC    SURGERY. 


small  remnants  of  the  lid  left  at  either  end  of  the  incision,  and  the  oper- 
ation is  not  rendered  more  difficult  by  a  total  extirpation  of  the  lid. 
The  tear-ducts  are  to  be  spared  only  if  they  lie  beyond  the  field  of 
operation. 

In  Dieffenbach's  method,  the  wound  has  to  be  brought  in  a  trian- 
gular form.  The  base  of  the  triangle  corresponds  to  the  lid-border 
(be)  (Fig.  56).  In  the  direction  of  the  base  an  incision  (ab)  is  per- 
formed outward  toward  the  temple,  somewhat  larger  than  the  defect 


FIG.  55. — Restoration  of  a  skin-defect  in  the  upper  and  lower  lid  (after  Fricke).  d,  de- 
fect ;  g,  pattern  of  guttapercha  paper,  cut  the  same  size  as  the  defect,  and  laid  on  the  place 
selected  before  excision  of  the  flap,  in  order  to  estimate  more  readily  the  size  of  the  latter; 
f ,  flap  to  be  cut  out. 


to  be  repaired,  as  the  flap  contracts  after  it  is  freed.  From  the  outer 
end  of  this  incision,  another  cut  is  carried  downward,  parallel  to  the 
outer  side  of  the  triangle.  A  flap  can  now  be  dissected  off,  the 
base  of  which  lies  below.  Sufficient  freeing  from  the  underlying 
tissue  affords  easy  rotation  inward  upon  the  defect.  The  upper  edge 
of  the  flap  is  sutured  to  the  remains  of  the  conjunctiva,  and  corresponds 
to  the  lid-margin,  wrhile  the  inner  edge  is  secured  to  the  neighboring 
skin  by  strong  sutures.  The  surface  from  which  the  flap  was  taken 
is  closed  in  as  much  as  possible  by  sutures  after  a  thorough  under- 


PLASTIC  OPERATIONS  ON  THE  EYELIDS. 


117 


mining  of  its  edges.     The  remainder  of  the  exposed  area  is  left  to 
heal  by  granulation. 

The  results  produced  by  this  method  of  operation  are  only  moder- 
ately satisfactory.  The  diseased  area  is,  it  is  true,  covered  in  by 
healthy  skin,  but  as  the  flap,  lacking  a  cartilaginous  substratum,  is 
yielding,  it  sinks  downward  continuously,  and  becomes  drawn  against 
the  eyeball  and  attached  directly  to  it  by  the  cicatrix.  The  conjunctiva 
is  also  materially  shortened,  the  movability  of  the  eyeball  is  usually 
considerably  lessened,  and  besides,  the  hairs  continuing  to  grow  from 
the  skin  of  the  flap,  in  a  short  time  cause  a  clouding  of  the  lower  half 
of  the  cornea. 


FIG.  56. — Restoration  of  a  lower  lid  after  Dieffenbach.  The  lower  lid  is  excised  in 
triangular  fashion;  that  is,  a  pre-existing  defect  is  brought  into  this  form.  Formation  of  a 
quadrangular  skin  flap  (a  b),  which  is  freed  from  its  underlying  tissues. 

The  combination  of  Diefifenbach's  method  with  the  plastic 
operation  making  use  of  the  ear-cartilage,  as  first  recommended 
by  Buediner,  represents  an  extraordinary  advance  in  the  treatment 
of  such  cases. 

After  the  skin-flap  has  been  freed  as  in  the  foregoing  description,  a 
flap,  including  not  only  the  skin  but  also  the  cartilage,  is  excised  from 
the  posterior  surface  of  the  ear.  It  should  be  as  long  as  the  lower 
lid,  have  a  straight  edge  corresponding  to  the  lid-margin,  and  a  second 
somewhat  convex  edge  corresponding  to  the  lower  border  of  the  tarsus. 
Because  of  the  narrowness  of  the  normal  tarsus  of  the  lower  lid,  we 
need  only  take  a  very  small  piece  of  cartilage  from  the  ear.  On  the 
contrary,  to  cover  the  wound-surface  we  must  take  a  much  larger 
piece  of  skin.  There  is  first  made  a  vertical  incision  of  adequate  length 


Il8  OPHTHALMIC    SURGERY. 

on  the  posterior  surface  of  the  ear.     This  will  at  once  retract  somewhat, 
and  at  the  point  of  retraction  an  incision  is  made  through  the  cartilage, 
corresponding  to  the  length  of  the  tarsus.     This  edge  of  the  flap  forms 
the  new  lid-margin.     Next  the  dissection  is  continued  3  mm.  further 
beneath  the  cartilage,  that  is,  between  cartilage  and  skin  of  the  anterior 
surface  of  the  ear,  and  the  cartilage  is  cut  through  from  in  front  with- 
out wounding  the  skin.     In  order  to  free  the  skin,  it  is  dissected  an 
additional  5  mm.  with  a  slightly  convex  incision.     In  consequence, 
the  freed  flap  shows  the  shape  viewed  from  the  raw  surface  (Fig.  57). 
As  the  ear-cartilage  is  too  thick,  it  is  shaved  down  by  cutting  away 
thin  lamellae  with  a  scalpel  applied  flatwise, 
until  it  approximately  equals  the  thickness  of 
a  normal    tarsus.      This  flap  is  fastened  by 
sutures  to  the  previously  dissected  skin-flap 
(Fig.   58),    so    that    the    wound-surfaces  are 
FIG.  57.—  Flap   from   the    apposed  to  each  other;  that  is,  the  skin  of  the 

posterior  surface  of  the  ear;  . 

c.,  cartilage;  w.  s.,  skin  seen    ear-flap  is  directed  posteriorly  toward  the  eye- 

from  the  wound-surface.  straight  edge  CQmes  to  He  against 


the  free  upper  margin  (ab}  of  the  pedicled  skin- 

flap.  In  order  to  avoid  unsightly  indentations  of  the  new  lid-margin 
by  pressure  of  the  sutures,  we  employ  sutures  armed  with  two  needles. 
Both  ends  are  pushed  from  behind  forward  through  the  skin  and  the 
cartilage,  2  mm.  below  the  free  margin.  They  are  tied  over  a  glass 
bead.  At  least  three  sutures  are  necessary.  In  like  manner  one  or 
two  sutures  are  brought  through  the  lower  border  of  the  skin-  and 
cartilage-flap  in  an  anterior  direction  and  tied,  in  order  to  secure  a 
firm  approximation  of  the  flap  to  its  new  base. 

The  pedicled  flap,  with  its  posterior  surface  thus  provided  with  a 
sufficiently  large  cutaneous  surface,  is  sutured  after  adequate  rotation, 
to  the  edges  of  the  defect,  as  in  Dieffenbach's  original  method.  To 
prevent  mechanical  injury  to  the  cornea  by  the  flap,  which  is  some- 
what stiff  at  first  and  readily  produces  erosions  and  ulcers,  I  am 
accustomed  to  draw  the  upper  lid  far  downward  by  two  stiches  passing 
through  its  margin,  and  to  bring  both  ends  of  each  suture  through  the 
base  of  the  flap,  which  has  been  rotated  inwrard;  not  until  then  is  the 
flap  fastened  to  its  new  position.  Thus  the  new  lower  lid  lies  at 
first  against  the  upper  lid.  The  defect  produced  externally  is  covered 
in  exactly  the  manner  described  by  Dieffenbach.  The  flap  of  skin  and 
cartilage  heals  in  promptly.  Both  eyes  are  bandaged  and  the  dressing 


PLASTIC  OPERATIONS  ON  THE  EYELIDS.  IIQ 

changed  for  the  first  time  after  two  days.  The  fixation-sutures  of 
the  upper  lid,  which  were  tied  over  small  gauze  pads,  are  allowed  to 
remain  as  long  as  they  hold.  They  cut  through  in  from  five  to  six 
days.  However,  the  upper  lid  continues  to  hang  down  for  several 
days  more,  completely  covering  the  cornea,  but  by  the  time  it  can  be 
elevated,  the  flap  of  skin  and  cartilage  have  long  since  healed,  and  in 
its  moist  environment  the  skin  has  become  so  delicate  that  an  in  jun- 
to the  cornea  need  no  longer  be  feared. 


FIG.  58. — The  flap  represented  in  Figure  57  is  here  so  sutured  to  the  posterior  side 
(that  is,  the  raw  surface)  of  the  pedicled  skin  flap  that  the  skin  (s)  comes  to  lie  posteriorly 
toward  the  eye.  The  flap  is  now  twisted  into  the  defect  of  the  lid  and  sutured  in  such  a 
fashion  that  (b)  comes  to  lie  in  apposition  to  c  and  a  of  the  flap  in  apposition  to  b  of  the 
canthus. 

The  flap,  which  at  first  seemed  too  thick  and  bulging  for  a  lower 
lid,  later  becomes  gradually  thinner.  It  resembles  quite  well  a  lower 
lid  deprived  of  its  eyelashes,  especially  as  it  stands  up  freely  owing  to 
its  cartilaginous  substratum,  and  is  not  drawn  against  the  eyeball 
through  the  formation  of  a  cicatrix.  This  method  is  particularly 
valuable,  because  the  motility  of  the  eyeball  remains  unaffected,  and 
a  deep  conjunctival  sac  is  created,  similar  to  the  normal.  Further- 
more, the  transplanted  flap,  free  of  hairs,  does  not  give  rise  to  corneal 
irritation.  These  are  sufficient  reasons,  to  undertake  Dieffenbach's 
method  only  with  the  proposed  modification. 

If  the  entire  upper  lid  must  be  extirpated  in  the  removal  of  a  neo- 


120  OPHTHALMIC    SURGERY. 

plasm,  the  eye  is  usually  lost;  but  an  attempt  should  be  made  to  restore 
the  upper  lid  by  a  flap,  which  is  formed  according  to  Fricke's  method, 
its  posterior  surface  being  covered  in  by  a  delicate  layer  of  epithelium 
taken  from  the  arm. 

OPERATIONS  FOR  SYMBLEPHARON. 

If  the  connection  between  the  conjunctival  surface  of  the  lid  and 
the  eyeball  is  in  the  form  of  isolated  bands,  which  interfere  with  the 
movements  of  the  eye  and  produce  diplopia,  an  indication  for  their 
division  exists  in  every  instance.  The  separation  of  the  cicatricial 
strands  must  be  followed  by  a  closure  of  the  resulting  wound,  in  order 
to  prevent  the  two  raw  surfaces  from  again  growing  together.  In  the 
case  of  small  strands,  closely-applied  sutures  will  usually  be  sufficient. 
The  neighboring  conjunctiva  must,  however,  be  loosened  so  that  the 
sutures  may  draw  it  over  the  defect;  incisions  in  the  surrounding  tissue 
to  relieve  tension  are  of  considerable  value. 

If  more  of  the  conjunctival  sac  is  affected,  that  is,  if  the  symble- 
pharon  is  broader,  there  will  not  be  enough  mucous  membrane  to  draw 
over  and  to  cover  the  defect.  In  this  event  it  is  necessary  to  dissect 
either  a  pedicled  flap  from  the  conjunctiva  of  the  neighborhood,  or  a 
flap  without  pedicle  from  a  suitable  point,  usually  the  upper  con- 
junctival fold,  or  it  may  be  taken  from  the  conjunctiva  of  the  patient's 
sound  eye. 

The  greater  number  of  the  symblepharon-operations  are  required 
to  the  lower  lid.  If  a  symblepharon  involving  the  lower  internal 
portion  of  the  conjunctiva  has  been  divided,  and  on  account  of  the  size 
of  the  defect  a  plastic  operation  is  indicated,  it  is  possible  to  take  a 
pedicled  flap  from  the  adjacent  conjunctiva  and  cover  the  defect  by 
rotating  it  over  the  wound  and  fastening  it  there  by  means  of  sutures. 
The  new  defect  produced  by  the  excision  of  the  flap  may  be  allowed 
to  cicatrize,  as,  lying  to  the  outer  side  of  the  wound  in  the  lid,  it  does 
not  give  rise  to  new  adhesions;  or  the  defect  may  be  covered,  as  well  as 
possible,  by  loosening  of  the  neighboring  structures  and  sutures. 

The  formation  of  pedicle  flaps  is,  however,  in  most  instances 
difficult,  and  it  is,  therefore,  preferable  to  cover  in  the  defect  in  the 
conjunctiva  of  the  eyeball  with  a  flap  taken  from  the  upper  conjunctival 
fold.  The  flap  is  held  in  its  new  position  by  several  delicate  silk 
sutures.  Naturally,  the  removal  of  this  flap  is  only  possible  when  the 
conjunctiva  of  this  fold  shows  no  cicatricial  changes.  The  normal 


PLASTIC  OPERATIONS  ON  THE  EYELIDS.  121 

fold  offers  ample  conjunctiva  for  broad  flaps,  but,  if  contracted,  the 
flap  may  be  taken  from  the  patient's  other  eye,  provided,  of  course, 
that  it  is  normal ;  this  gives  the  greatest  chances  of  satisfactory  healing. 

From  personal  experience  it  may  be  stated,  that  all  similar  proceed- 
ings with  mucous  membrane  from  a  rabbit  are  to  be  completely  re- 
jected. Even  if  the  graft  is  successful,  which  is  much  more  uncertain 
than  when  human  conjunctiva  is  employed,  the  animal  mucous  mem- 
brane subsequently  contracts  so  greatly  that  the  good  effect  pro- 
duced is  entirely  lost. 

In  all  methods  of  covering  the  defects  with  conjunctiva,  we  must  be 
content  to  do  so  over  only  one  of  the  wounds,  as  flaps  large  enough 
for  the  wound  in  the  eyelid  cannot  be  obtained.  Though  the  covering 
of  the  one  defect  is  sufficient  in  most  cases,  it  is  always  better  to  have 
both  wounds  provided  with  epithelium,  not  only  to  prevent  the  for- 
mation of  a  new  symblepharon  in  case  the  single  flap  does  not  heal  in 
properly,  but  because  the  scar  arising  from  the  uncovered  wound  may 
contract  later  on  and  gradually  draw  the  lid  inward  and  cause  trichiasis; 
or  result  in  limitation  of  motion  of  the  eyeball.  For  the  foregoing 
reasons  many  plastic  methods  have  been  devised,  intended  to  cover 
the  wound  in  the  lid.  The  various  methods,  as  in  all  plastic  oper- 
ations, consist  either  in  applying  a  pedicled  flap  from  the  neighboring 
skin  or  a  free  flap  of  epidermis. 

In  cases  of  complete  symblepharon  of  the  lower  lid  the  repair  of  the 
lid-wound  is  especially  imperative.  The  defect  on  the  eyeball  is  too 
large  to  be  covered  in  its  entirety  by  conjunctiva  taken  from  other 
places.  We  have  repeatedly  employed  in  these  cases  a  combination 
of  conjunctival  and  skin-flap  with  good  results.  After  thoroughly 
dividing  the  scar  and  covering  the  wound  on  the  eyeball  with  a  pedicled 
flap  taken  from  the  upper  conjunctival  fold,  the  wound  in  the  lid  should 
be  covered  by  a  skin-flap,  which,  following  Rogman's  method,  may 
be  taken  from  the  lower  lid  itself.  From  the  skin  of  the  lower  lid 
(Fig.  59)  a  flap  (abed)  is  made,  the  base  (ad)  of  which  is  situated 
directly  at  the  upper  level  of  the  conjunctival  fold  in  need  of  recon- 
struction. This  flap  is  as  long  and  as  high  as  the  lid.  Next,  an 
incision  beginning  at  the  lower  level  of  the  conjunctival  fold  and 
corresponding  to  the  line  (ad),  divides  all  the  structures  in  such"  a 
manner  as  to  leave  only  the  skin  intact.  It  is  then  an  easy  matter 
to  rotate  the  flap  in  through  the  slit  so  made.  This  should  be  done 
so  that  its  raw  surface  is  turned  toward  the  wound  in  the  lid,  and  the 


122 


OPHTHALMIC    SURGERY. 


margin  (be}  of  the  flap  may  be  fastened  with  sutures  to  the  margin 
of  the  lid.  The  flap  is  certain  to  become  attached,  as  its  base  remains 
connected  to  the  surrounding  tissues.  The  wound  on  the  outside  of  the 
lid  is,  as  far  as  possible,  tied  by  sutures.  At  first,  however,  there  is  a 
slit  left  through  which  the  new  conjunctival  sac  can  be  reached  from 
the  outer  side.  After  about  eight  days,  the  connection  is  severed; 
the  slit  now  rapidly  closes  through  cicatrization.  Rogman,  in  his 
original  method,  repeated  this  procedure  at  a  later  date  by  rotating 
through  the  slit  another  flap  formed  from  the  still  remaining  skin  on 


FIG.  59. — Operation  for  symblepharon  after  Rogman.  After  separation  of  the  symble 
pharon  between  the  eyeball  and  the  lower  lid,  there  is  formed  from  the  skin  of  the  lower 
lid  the  flap  (abed);  it  has  its  base  at  a  d.  This  flap  is  rotated  backward  through  a  slit 
in  such  a  fashion  that  the  edge  (b  c)  can  be  sutured  to  the  palpebral  margin  and  the  skin — 
serving  the  function  of  a  palpebral  conjunctiva — is  turned  toward  the  eyeball.  There  is 
rotation  of  180°. 

the  lower  lid.  I  much  prefer  the  foregoing  combination  to  Rogman's 
original  method,  as  there  is  too  little  skin  available  for  the  second 
plastic  operation  on  the  lid. 

The  best  method  to  thoroughly  remove  a  total  symblepharon 
is  as  follows:  The  scar  is  divided  as  in  the  other  methods  by  means 
of  a  scalpel,  and  an  external  canthoplasty  performed.  From  the  end 
of  the  skin-incision,  a  cut  3  cm.  long  is  made  outward  and  down- 
ward. From  this  point  on,  the  skin  is  dissected  off  toward  the  lid, 
until  finally  the  entire  lower  lid  can  be  reflected  toward  the  nose  as  a 
free  flap.  The  dissection  must  be  carried  beyond  the  scar-area  into 
the  healthy  tissue,  so  that,  finally,  there  is  a  large  raw  surface  which 
stretches  in  one  plane  from  the  limbus  to  the  lid-border.  After  this, 
a  large  skin-flap  of  a  suitable  shape  is  dissected  from  the  delicate  skin 


PLASTIC  OPERATIONS  OX  THE  EYELIDS.  123 

of  the  upper  arm,  according  to  the  rules  already  mentioned  (see 
Cicatricial  Ectropion,  p.  52),  and  fitted  accurately  to  the  raw  surface 
up  to  the  palpebral  fissure.  The  flap  may  be  sewed  with  several  fine 
sutures  to  the  lid-margin  on  the  one  side,  and  to  the  limbus  on  the 
other.  As  the  lid  is  now  turned  back  again  into  its  original  position, 
the  flap  folds  up  properly  of  itself,  the  place  doubled  down  representing 
the  new  fornix.  In  order  to  fix  the  fold  in  this  position,  two  sutures 
are  carried  through  from  this  spot  out  to  the  cutaneous  surface,  and 
their  ends  tied  outside  over  gauze.  The  operation  is  completed  by 
the  suturing  of  the  incisions  made  at  the  beginning.  Both  eyes  are 
bandaged  and  the  dressing  changed  for  the  first  time  at  the  end  of 
three  days. 

The  fornix  is  at  first  adnormally  deep,  but,  later,  diminishes  in 
size  through  contraction,  without,  however,  shrinking  so  much  as  to 
prevent  free  movement  of  the  eye  on  the  comfortable  wearing  of  a 
prothesis.  In  these  cases  we  must  begin  to  insert  a  prothesis  quite 
early,  and  to  make  eventually  properly  fitting  protheses  from  Stent's 
composition,  a  substance  used  by  dentists  for  taking  impressions. 
Such  protheses  extend  deeply  down  into  the  fornix. 

Insertion  of  an  unpedicled  flap  without  making  the  incision 
proposed  is  not  recommended,  as  the  limited  space  makes  the  operation 
more  difficult,  and  an  adequate  adaptation  of  the  flap  is  impossible. 
It  is  only  by  accident  that  such  a  flap  heals  in  properly.  Likewise, 
the  same  can  be  said  about  the  proposition  of  laying  the  unpedicled 
flap  over  the  prosthesis  in  such  fashion  that  its  epithelial  surface  is 
turned  toward  the  latter,  the  prothesis  with  this  covering  being  inserted 
after  cutting  through  the  scar. 


CHAPTER  XI. 
EXTRACTION  OF  SENILE  CATARACT. 

The  accompanying  illustrations  have  all  been  made  from  photo- 
graphic views,  and  are  intended,  primarily,  to  reproduce  faithfully  the 
position  of  the  hands  of  the  operator  as  well  as  those  of  his  assistant 
during  the  different  operative  procedures.  This  can  be  accomplished 
better  by  a  picture  (especially  a  photograph)  than  by  the  most  exten- 
sive description.  In  so  far  as  possible,  the  operative  procedure  on 
the  eye  itself  is  also  delineated  sufficiently  well  in  the  same  illustration. 
However,  when  it  seemed  necessary,  the  operation  on  the  eye  has  been 
represented  by  itself  in  accompanying  diagrams.  The  photographs 
were  taken  from  the  operator's  side.  In  order  to  render  recognition 
easier,  the  hands  of  the  operator  are  indicated  by  the  latter  o;  those 
of  the  assistant,  by  the  letter  a.  In  all  instances  the  operator  sits  to 
the  right  of  the  patient,  while  the  assistant  stands  to  the  left.  The 
relative  positions  assumed  by  the  hands  and  the  fingers  of  the  operator 
and  assistant  should  be  observed.  The  figures  show  clearly  how 
the  hands  are  supported,  how  the  instruments  are  held,  etc. 

TECHNIC. 

The  technic  of  the  various  steps  of  the  operation  will  first  be  con- 
sidered, and  then  the  complications  which  may  occur  in  each  of  these 
steps. 

i.  Fixation  of  the  Eye  (Figs.  60  and  61). — It  is  best  to  sit  at  the 
right  of  the  patient  who  is  lying  upon  the  operating  table.  The 
incision  is  made  from  the  outer  side,  on  the  right  eye  with  the  left 
hand,  and  on  the  left  eye  with  the  right  hand,  the  other  hand  being 
engaged  in  the  fixation  of  the  eyeball.  For  this  purpose  an  ordinary  pair 
of  toothed  fixation  forceps  with  three  dentations  is  held  between  the 
thumb  and  forefinger.  The  forceps  must  be  applied  perpendicularly 
to  the  sclera  and  quite  near  the  limbus,  so  as  to  get  hold  of  a  tight  fold 
of  the  conjunctiva.  If  the  conjunctiva  is  seized  at  even  a  slight 
distance  from  the  limbus,  the  fold  picked  up  is  so  loose  that  the  eye 
is  not  sufficiently  fixed.  During  the  cataract-incision  the  forceps 

124 


EXTRACTION  OF  SENILE  CATARACT. 


125 


at  the  lower  part  of  the  limbus  grasps  the  eye  exactly  in  its  vertical 
meridian.  The  operator  at  the  right  of  the  patient  finds  no  difficulty 
in  fixation  of  the  right  eye,  as  the  forceps  held  in  the  right  hand  are 
placed  directly  opposite  to  the  right  eye,  but  it  is  not  so  easy,  especially 
for  the  beginner,  to  fix  the  left  eye  from  the  position  mentioned.  To 
this  end  the  left  upper  arm,  with  the  elbow  in  a  strongly  flexed  position, 


FIG.  60. — Beginning  of  the  cataract-incision  in  the  left  eye.  While  the  assistant  holds 
the  eye  open  according  to  the  rules  given  on  page  236,  the  forceps  held  in  the  left  hand 
grasp  the  eye  below,  close  to  the  limbus  and  exactly  in  the  vertical  meridian.  The  patient 
during  this  procedure  looks  well  downward.  The  knife  held  in  the  right  hand  with  its 
edge  directed  upward  is  applied  exactly  at  the  limbus  and  is  held  horizontal  and  parallel  to 
the  plane  of  the  iris. 

is  pressed  firmly  against  the  chest,  while  the  hand,  itself  bent  dorsally, 
guides  the  forceps  held  between  thumb  and  forefinger,  vertically  to 
the  lower  portion  of  the  limbus,  where  the  fold  is  raised.  Through 
this  unaccustomed  position  of  the  arm,  the  beginner  very  easily  falls 
into  the  error  of  pressing  upon  the  eye  instead  of  pulling  forward,  a 
mistake  that  is  frequently  the  cause  of  unpleasant  complications. 


126 


OPHTHALMIC    SURGERY. 


The  fold  of  the  conjunctiva  must  be  raised  exactly  in  the  vertical 
meridian.  Since  the  operation  is  performed  in  most  cases  with  an 
iridectomy,  it  is  essential  that  the  incision  be  made  accurately  above, 
so  that  the  coloboma,  which  corresponds  to  the  central  portion  of  the 
cut,  will  also  be  directed  upward,  and  be  completely  covered  by  the 
upper  lid.  If,  however,  the  eyeball  is  grasped  sideways,  for  example, 


FIG.  61. — Beginning  of  the  cataract-incision  in  the  right  eye,  the  operator  and  the  assist- 
ant occupying  the  same  position.  The  eye  is  fixed  with  the  right  hand,  the  knife  is  held 
in  the  left'. 

at  the  end  of  the  horizontal  meridian,  a  rotation  of  the  eye  is  unavoid- 
able, as  the  eye  must  be  drawn  continually  downward  during  the 
incision,  in  order  to  expose  the  upper  corneal  margin.  In  consequence 
of  this  rotation  the  incision  is  placed  in  an  oblique  and  undesirable 
position,  and  with  it  also  the  coloboma.  If  the  eye  is  fixed  below, 
exactly  in  the  vertical  meridian,  there  ensues  no  rotation,  so  that  no 
mistake  can  be  made  concerning  the  situation  of  the  incision.  In 


EXTRACTION  OF  SENILE  CATARACT.  127 

inserting  the  knife,  it  is  true  that  the  eye  may  rotate  slightly  out  of 
its  position,  but  this  can  not  further  displace  the  incision.  By  means 
of  the  elevated  fold  the  eye  is  drawn  not  merely  downward,  but  also 
slightly  forward.  During  the  incision  the  patient  is  directed  to  look 
well  downward. 

2.  The  incision  (Figs.  60  to  64)  is  probably  the  most  difficult  part 
of  the  operation  and  demands  the  most  detailed  description.  It  is 
made  with  the  narrow  Graefe  cataract-knife.  It  is  executed  in  an 
upward  direction,  should  include  about  one-third  of  the  corneal 


FIG.  62. — Diagram  showing  the  point  of  the  knife  directed  toward  a  point  in  the  cornea 
about  i  mm.  within  the  limbus,  so  as  to  begin  the  counterpuncture. 

periphery,  and  in  its  entire  length  should  run  in  the  limbus  or  close 
behind  it. 

While  inserting  the  knife  its  point  is  placed  on  the  limbus  externally 
1-2  mm.  above  the  end  of  the  horizontal  meridian,  while  it  is  held 
horizontally  between  the  thumb  and  first  and  second  fingers.  Mean- 
while, the  hand  is  supported  by  the  little  finger  placed  on  the  patient's 
head  (Figs.  60  and  61).  The  edge  of  the  knife  is  directed  upward 
and  the  blade  is  parallel  to  the  surface  of  the  iris.  The  point  of  the 
knife  pierces  the  eye  at  the  limbus,  and  is  pushed  without  a  pause 


FIG.  63. — Diagram  showing  the  point  of  the  knife  thrust  just  through  at  the  limbus. 

through  the  anterior  chamber  in  order  that  the  counteropening  inter- 
nally is  made  in  a  symmetrical  position.  Here  it  should  be  emphasized 
that  the  chief  factor  in  the  success  of  an  incision,  which  is  to  open  the 
anterior  chamber,  is  the  avoidance  of  any  pause  or  retrograde 
movement. 

The  most  difficult  point  for  beginners  is  to  make  the  counter  punc- 
ture in  ;he  proper  position.  To  their  astonishment,  most  novices 
find  the  knife  emerging  in  the  sclera  behind  the  limbus.  The  reason  for 
this  error  is  clearly  understood  from  a  study  of  the  anatomical  relations 
of  the  anterior  chamber  (Figs.  62  and  63).  The  limbus  extends  much 


128  OPHTHALMIC    SURGERY. 

further  (2  mm.)  anteriorly  than  the  angle  of  the  anterior  chamber. 
If  the  knife  is  brought  as  far  as  this  angle,  the  inevitable  consequence 
is  that  the  counterpuncture  is  performed  in  a  faulty  place  far  beyond 
the  limbus.  In  order  that  it  is  made  either  directly  at  the  limbus,  or 
close  to  it,  the  knife  must  be  directed  to  a  point  in  the  cornea  about 
i  mm.  from  the  limbus,  where,  as  viewed  from  in  front,  transparent 
cornea  is  still  present.  The  impression  thus  given  is  that  the  knife 
will  appear  at  the  surface  in  transparent  cornea,  but  to  the  operator's 
surprise  the  point  emerges  in  the  limbus.  The  beginner  is,  therefore, 
usually  told  to  direct  the  point  of  the  knife  toward  a  spot  in  the  cornea, 
situated  about  i  mm.  distant  from  the  limbus. 

After  completing  the  counterpuncture  the  knife  is  steadily  carried 
upward  in  sawing  movements,  at  all  sides  parallel  to  the  limbus. 
This  procedure  is  somewhat  troublesome  for  the  beginner,  as  he  must 
cut  away  from  himself  in  a  manner  to  which  he  is  not  accustomed. 
A  keen-edged  knife  readily  passes  through  the  tunics  of  the  eye,  so 
that  the  incision  can  be  completed  in  two  or  three  drawing  motions. 
Short  sawing  motions  must  be  avoided,  as  they  produce  an  irregular 
wound.  The  reason  that  the  beginner  frequently  does  not  advance 
the  knife,  in  spite  of  many  short  sawing  movements,  lies  usually  in  the 
fact  that  instead  of  pushing  the  edge  upward,  he  presses  the  knife 
backward  toward  the  sclera. 

After  completion  of  the  counterpuncture,  the  incision  should  be  con- 
tinued without  delay,  in  order  to  pass  smoothly  over  the  pupillary  margin 
before  evacuation  of  the  aqueous  humor.  If  the  completion  of  the 
incision  is  delayed,  the  anterior  chamber  is  abolished  and  the  iris  falls 
in  the  way  of  the  knife,  and  is  unavoidably  injured.  To  pause  after 
the  counterpuncture,  however,  is  a  very  common  error  with  beginners. 
If  properly  executed,  the  sawing  movements,  claimed  by  many  to  be 
so  disadvantageous,  cause  no  inconvenience  whatever.  In  this  way 
with  a  keen-edged  knife  the  incision  may  be  completed  in  two  move- 
ments by  sawing  sections  just  as  well  as  when  it  is  performed  by 
elevating  and  lowering  the  handle  of  the  knife. 

During  the  incision  the  knife  must  remain  exactly  parallel  to  the 
iris,  as  any  turning  of  the  edge  forward  or  backward  would  naturally 
result  in  a  deviation  of  the  cut,  either  into  the  cornea  or  into  the  sclera. 
Only  after  cutting  through  the  outer  tunic  of  the  eye,  and  the  knife 
is  seen  under  the  conjunctiva,  is  it  recommended  to  turn  the  blade 
through  an  arc  of  90  degrees  (Fig.  64),  so  that  the  edge  looks  anteriorly. 


EXTRACTION  OF  SENILE  CATARACT.  I2Q 

This  secures  a  conjunctival  flap  that  is  much  shorter  than  if  the 
knife  in  the  previous  position  had  been  permitted  to  cut  through.  A 
long  conjunctival  flap  is  an  unpleasant  impediment  to  a  proper  per- 


FIG.  64. — In  this  illustration  the  incision  has  advanced  so  far,  that  the  cornea-sclera 
is  already  cut  through  and  the  knife  i>,  beneath  the  conjunctiva.  In  order  to  cut  the  flap 
off  short,  the  knife  is  turned  in  such  a  manner  that  the  edge  looks  forward.  The  knife  is 
now  turned  up.  Note  the  change  in  the  position  of  the  hands  of  the  operator  as  compared 
with  Fig.  60.  The  line  of  the  incision  in  the  cornea-sclera,  as  far  as  it  lies  behind  the  base 
of  the  conjunctival  flap,  is  designated  by  dots. 

formance  of  the  operation.     The  incision  having  been  completed,  the 
forceps  are  released  and  the  rest  of  the  operation  finished  without  fixation. 
3.  Iridectomy.   (Figs.  65  to  68). — In  this  procedure  there  are  used 
iris-scissors  (De  Weckcr's  pince-ciseaux  Fig.  69)  and  the  iris-for- 
ceps (Fig.  70.)     The  patient  looks  well   downward,  and  the  closed 
9 


130  OPHTHALMIC    SURGERY. 

forceps,  held  in  the  left  hand  between  thumb  and  forefinger  are  in- 
troduced vertically  from  above,  through  the  wound  alongside  of  the 
iris,  to  the  pupillary  margin,  with  the  concavity  of  the  blade  forward. 
The  forceps  are  then  opened  slightly  and  a  narrow  fold  of  iris  is 
seized,  drawn  forward  and  quickly  cut  off  with  the  scissors  held  in  the 


FIG.  65. — Second  step.  Iridectomy. — The  eye  is  fixed  no  longer.  With  the  thumb 
of  the  right  hand,  the  assistant  holds  the  upper  lid  up  from  the  side  in  such  a  manner  that 
the  operator  is  not  hindered  in  inserting  the  closed  iris-forceps  directly  from  above  through 
the  wound  to  a  point  very  near  to  the  pupillary  margin.  The  right  hand  meanwhile  holds 
the  iris-scissors  already  opened  close  by,  ready  to  quickly  cut  off  the  iris  as  soon  as  it  is 
drawn  forward.  For  the  sake  of  clearness  the  conjunctival  flap  is  not  represented  on  this 
and  the  following  figures. 

right  hand  (Figs.  65  to  68).  The  hand  guiding  the  forceps  must  take  a 
position  of  marked  flexion,  in  order  to  introduce  the  instrument 
exactly  from  above.  Should  the  conjunctival  flap  interfere  with  the 
introduction  of  the  forceps,  it  may  be  turned  down  over  the  cornea 
by  aid  of  the  closed  scissors,  while  the  forceps  press  the  scleral  edge 
of  the  wound  slightly  back. 


EXTRACTION  OF  SENILE  CATARACT.  131 

The  arms  of  the  pince-ciseaux  are  best  directed  upward  during  the 
excision  (Fig.  68),  as  by  this  maneuver  we  obtain  most  readily  a  narrow 
coloboma  having  the  form  of  a  pointed  arch.  It  is,  however,  no  mis- 
take to  make  the  cut  with  the  arms  of  the  scissors  held  parallel  to  the 
limbus. 

4.  In  opening  the  anterior  lens-capsule  (Figs.  73  to  75)  we  employ 


FIG.  66. — The  blades  of  the  iris-forceps  held  close  to  the  pupillary  margin 
have  just  been  opened.  Figs.  59  to  61  show  in  natural  size  the  maneuvers 
in  seizing  and  extracting  the  iris. 

capsule-forceps  (Figs.  71  and  72).  The  manipulation  of  this  instrument 
is,  it  is  true,  somewhat  more  difficult  than  that  of  cystotome.  The 
operator  holds  the  forceps  in  the  right  hand  between  the  thumb  and 
forefinger,  and  raises  the  upper  lid  of  the  patient  with  his  left  hand, 


FIG.  67. — The  blades  have  been  closed  and  have  seized  a  fold  of  the  iris. 

while  the  assistant  draws  the  lower  lid  slightly  away  from  the  eye, 
the  patient,  meanwhile,  looking  well-downward.  The  closed  instru- 
ment is  introduced  vertically  from  above  (hence  a  position  of  the 
hand  analogous  to  that  in  iridectomy),  and  pushed  forward  into  the 


FIG.  68. — The  portion  of  the  iris,  which  has  been  drawn  forward,  is  cut  off 
by  the  scissors  brought  from  below. 

anterior  chamber  until  the  dentated  parts  of  the  arms  lie  in  the  pupil, 
while  their  posterior  portion  is  situated  in  the  coloboma. 

The  forceps  must  be  in  such  a  position  that  both  arms,  when  opened, 
glide  along  the  surface  of  the  anterior  capsule  (Fig.  74).  A  common 
mistake  of  the  beginner  is  to  hold  the  forceps  obliquely  so  that  only 
one  arm  lies  against  the  capsule,  while  the  other  rests  a  greater  or 
lesser  distance  away  in  the  chamber.  After  the  forceps  have  been 


132  OPHTHALMIC    SURGERY. 

placed  properly  on  the  capsule,  the  instrument  is  opened  as  widely  as 
the  size  of  the  pupil  permits,  although  still  greater  opening  may  be 
obtained  by  permitting  the  arms  to  push  the  pupillary  margin  of  the 
iris  gently  back.  Next,  under  a  slight  degree  of  pressure  exerted  in  the 


FIG.  69. — Iris-Scissors  (Pince-Ciseaux,  de  Wecker). 

direction  of  the  lens,  the  forceps  are  again  closed,  and  a  fold  of  the 
capsule  seized  between  the  teeth,  which  are  directed  inward  (Fig.  75), 
and  torn  loose  from  its  surroundings  by  a  slow  pulling  movement. 


FIG.  70. — Iris-forceps. 

The  capsule-opening  must  be  performed  gently,  and  especially  must  the 
separated  piece  of  capsule  be  drawn  slowly  from  the  eyeball  in  order 
that  it  be  not  detached  from  the  forceps  and  left  folded  up  in  the 
wound. 


FIG.  71. — Capsule-forceps  open  (side  view.) 

After  withdrawing  the  forceps  it  is  desirable  to  ascertain  that  the 
piece  of  capsule  is  in  their  grasp  and  does  not  by  any  mischance  re- 
main behind  in  the  wound.  Ordinarily,  there  is  obtained  a  some- 
what round  piece  of  the  anterior  capsule,  which  is  usually  about  the 


FIN.  72. — Capsule-forceps  closed,  showing  the  toothed  portions  only  in  contact. 

size  of  the  pupil  but  may  sometimes  be  much  larger.  The  degree  of 
pressure  needed  to  raise  up  a  fold  of  capsule  is  very  slight;  if  too  much 
is  exerted,  there  is  obviously  danger  of  luxating  the  lens.  In  order 
to  avoid  seizing  the  iris,  the  forceps  must  be  constructed  in  such  a 


EXTRACTION  OF  SENILE  CATARACT.  133 

way  that,  when  closed,  the  posterior  portions  of  the  arms  remain  apart 
from  each  other,  and  besides,  in  raising  up  the  fold  of  the  capsule,  the 
forceps  are  so  held,  that  only  the  toothed  edges  impinge,  while  the 
posterior  parts  of  the  arms  are  free  in  the  chamber  (Fig.  72).  In  extrac- 


, 


S, 


FIG.  73. — Third  step.  Opening  of  the  capsule.  The  eye  is  not  fixed.  The  operator 
himself  is  holding  the  upper  lid  elevated  with  his  left  hand,  while  with  the  right  he  is  just 
beginning  to  introduce  parallel  to  the  plane  of  the  capsule  the  closed  capsule-forceps. 
The  assistant  holds  the  lower  lid  slighty  away  from  the  eye,  not  only  to  freely  expose  the 
cornea,  but  also  to  prevent  any  pressure  on  the  eye  by  the  lid  should  it  be  forcibly  con- 
tracted by  the  patient.  The  other  hand  of  the  assistant  holds  the  spoon  directed  toward 
the  upper  lid  in  such  a  manner  that  he  can  bring  it  at  any  time  and  at  once  beneath  the  lid, 
if  the  patient  should  begin  to  wince  and  there  would  be  danger  of  his  pressing  the  upper 
lid  into  the  wound. 

tion  with  iridectomy  this  factor  plays  no  role,  as  the  posterior  portions 
of  the  arms  lie  within  the  confines  of  the  coloboma.  On  the  other 
hand,  in  extraction  without  iridectomy,  it  is  important,  by  these  precau- 
tionary measures,  to  prevent  a  pinching  of  the  iris. 

Of  greater  relative  simplicity  is  the  opening  of  the  anterior  capsule 


134  OPHTHALMIC    SURGERY. 

by  means  of  the  pointed  tenaculum  of  the  cystotome.  During  the 
introduction  into  the  anterior  chamber  the  tenaculum  should  be  made 
to  slide  down  close  to  the  posterior  surface  of  the  cornea  and  parallel 
to  it,  so  as  not  to  become  entangled.  When  it  reaches  the  pupillary 
area,  it  turns  through  an  arc  of  90  degrees  until  the  point  is  directed 
backward.  It  is  then  brought  into  contact  with  the  anterior  lens- 


FIG.  74. — Diagram  showing  both  blades  of  the  capsule-forceps 
widely  opened  gliding  over  the  anterior  capsule. 


capsule,  and  several  superficial  cuts  are  made  in  various  directions. 
During  this  procedure,  no  degree  of  force  is  either  necessary  or  per- 
missible. The  instrument  is  withdrawn  from  the  eye  in  the  same 
manner  as  it  was  introduced,  that  is,  parallel  to  the  corneal  surface. 
The  great  advantage  of  the  capsule-forceps,  which  outweighs  the 


FIG.  75. — The  blades  have  been  closed  and  have  grasped  between 
them  a  fold  of  the  capsule  which  is  now  being  pulled  out. 

disadvantage  of  its  somewhat  more  difficult  manipulation,  lies  in 
the  fact  that  a  large  opening  is  made  in  the  anterior  capsule  directly  in 
the  pupillary  area.  The  result  of  this  loss  of  tissue  is  that  the  capsule 
cannot  produce  optical  disturbances  later  on.  Again,  the  remnants 
of  the  cataract  left  behind  in  the  capsule-sac  are  exposed  to  the  action 
of  the  aqueous  humor,  with  the  result  that  even  in  the  operation  for 
unripe  cataract  01  when  a  large  number  of  cataract-remnants  are  pres- 
ent, they  usually  undergo  spontaneous  absorption  immediately  after 
the  operation. 

5.  Expression  of  the  Cataract  (Figs.  76  and  77). — The  patient 
looks  downward;  the  eye  is  not  fixed.  The  manipulations  which  the 
operator  must  perform  in  order  to  deliver  the  lens  from  the  eye  are 
comprised  in  two  different  acts.  While  the  upper  lid  is  raised  by 


EXTRACTION  OF  SENILE  CATARACT. 


the  thumb  of  the  left  hand,  the  forefinger  of  the  right  hand  begins 
to  exert  pressure  through  the  lower  lid  in  an  anterior-posterior 
direction  against  the  region  of  the  lower  corneal  margin.  The  immc- 


FIG.  76. — Kxpression  of  the  lens.  The  manner  in  which  the  operator  holds  his  hands 
should  be  observed.  With  the  thumb  of  his  left  hand,  he  raises  the  upper  lid  and  at  the 
same  time  pulls  it  slightly  away  from  the  eyeball.  The  forefinger  of  the  right  hand  exerts 
pressure  on  the  lower  half  of  the  cornea  through  the  lower  lid;  this  causes  gaping  of  the 
wound  and  the  edge  of  the  lens  presents  in  the  wound.  The  assistant  holds  the  spoon, 
as  already  described,  ready,  on  the  one  hand,  to  care  for  the  upper  lid  and,  on  the  other, 
to  roll  the  lens  completely  out  of  the  eye  after  it  has  protruded  half  way. 

diate  result  is  that  the  lens  rotates  upon  its  horizontal  frontal  axis  in 
such  a  way  that  the  upper  edge  of  the  lens-nucleus  is  turned  anteriorly, 
and  presents  in  the  wound,  a  procedure  which  the  operator  has  to 


136  OPHTHALMIC    SURGERY. 

watch  very  closely.  The  wound  begins  to  gape  and  in  it  the  edge  of  the 
lens  begins  to  appear.  This  pressure  must  be  made  with  great  caution, 
and  only  with  gradually  increasing  force,  in  order  to  prevent  a  rupture 
of  the  hyaloid  membrane. 

From  the  moment  the  edge  of  the  lens  presents  in  the  wound,  the 
direction  of  the  pressure  is  to  be  changed  from  below  upward,  as  a 
further  continuance  of  the  backward  pressure  would  only  cause  the 
vitreous  to  appear.  The  lens  is  now  pushed  up  and  out  of  the 
wound  by  a  stroking  movement  exerted  on  the  eye  with  the  assist- 
ance of  the  lower  lid.  It  is  not  permissible,  however,  to  stroke  up- 
ward above  the  middle  of  the  cornea,  as  this  would  compress  the 


FIG.  77. — Diagram  showing  the  spoon  just  about  to  be  applied  to  the  lateral 
margin  of  the  half -delivered  lens  so  as  to  roll  it  completely  out. 

wound  and  cause  the  lens  to  retreat  into  the  eye.  As  soon  as  the  upper 
half  of  the  lens  has  passed  the  wound,  the  assistant  applies  the  spatula 
to  the  margin  of  the  nucleus  and  removes  it  from  the  eye  (Fig.  77). 
At  the  same  time  the  operator  ceases  pressure.  The  presentation  of 
the  lens-border  in  the  wound  can  be  facilitated  by  a  slight  depression  of 
the  scleral  edge  of  the  wound  through  the  aid  of  Daviel's  spoon.  In 
the  average  case,  however,  this  is  not  necessary,  and  we  only  use  this 
depression  when  the  delivery  of  the  lens  is  accompanied  by  some 
difficulty. 

After  the  exit  of  the  lens,  the  upper  lid  is  at  once  guided  carefully 
down  over  the  eye,  so  as  to  prevent  the  wound  from  gaping.  Through 
similar  stroking  and  kneading  motions,  any  cortical  remnants  still 
remaining  behind,  are  brought  out  through  the  wound.  The  more 
carefully  this  is  done,  the  less  likelihood  there  will  be  of  secondary 
cataracts.  Sometimes  lens-tissue  remnants  are  brought  up  from 
below  behind  the  iris  by  this  massage,  and  the  pupil,  which  at  the 
outset  appeared  black,  turns  gray  again  until  the  particles  of  tissu  e 


EXTRACTION  OF  SENILE  CATARACT. 


137 


have  passed  into  the  wound.  Their  removal  is,  at  times,  anything  but 
easy.  Occasionally  they  can  be  got  out  by  inserting  David's  spoon 
into  the  anterior  chamber.  But  while  doing  this  the  operator  must  not  go 
too  far  in  his  endeavor  to  get  the  pupil  as  clean  as  possible.  As  soon 
as  it  is  seen  that  the  wound  shows  an  inclination  to  gape,  and  the  vitreous 
is  bulging  forward  and  is  in  danger  of  prolapse,  it  is  better  to  desist 


FIG.  78. — Reposition  of  the  inner  margin  of  the  coloboma.  The  eye  is  not  fixed.  The 
operator  himself  holds  the  upper  lid  in  the  same  manner  as  above.  His  right  hand  intro- 
duces the  spatula  from  without,  obliquely  into  the  inner  angle  of  the  wound,  in  order  to 
smooth  the  iris  down  from  this  point.  The  lower  lid  is  drawn  slightly  away  by  the  assistant. 

from  attempts  at  removal  of  the  remnants,  and  to  end  the  operation. 
It  may  happen  that  although  the  pupil  is  thought  to  be  free  of  cortical 
substance,  on  the  day  after  the  extraction  it  is  found  to  be  full  of 
swollen  masses  of  lens  material.  At  the  time  of  the  operation  this 
material  was  transparent,  and,  of  course,  could  not  be  detected. 

6.  Toilet  of  the  Eye  (Fig.  78  to  81).—  This  represents  the  final 
stage  of  the  operation,  and  the  most  important  part  in  it  is  the  reposi- 


138 


OPHTHALMIC    SURGERY. 


tion  of  the  iris.     After  removal  of  the  lens  it  is  often  hard  to  recog- 
nize whether  the  iris  is  really  in  a  correct  position. 

We  cannot  expect  to  see  in  every  case  sharply  projecting  sphincter- 
angles.  Occasionally  the  iris  has  been  excised  in  such  a  manner  that 
one  of  the  angles  produced  is  extraordinarily  obtuse.  Of  only  really 
great  importance  is  the  position  of  the  sphincter,  which  can  be  recog- 
nized through  its  color  being  different  from  that  of  the  rest  of  the  iris. 


FIG.  79. — Reposition  of  the  outer  margin  of  the  coloboma. — The  operator  himself  holds 
the  upper  and  lower  lids  by  means  of  the  thumb  and  forefinger  of  the  right  hand,  while 
the  spatula  is  introduced  with  the  left  hand  from  the  inner  side  obliquely  into  the  outer 
angle  of  the  wound  and  the  iris  smoothed  back. 

It  is  true,  however,  that  through  the  presence  of  hemorrhages  on  the  iris, 
a  proper  view  can  be  hindered.  The  reposition  is  achieved  by  the  spatula 
which  is  pushed  carefully  through  the  lips  of  the  wound  into  its  angle 
(Fig.  80).  The  spatula  must  be  held  parallel  to  the  plane  of  the  iris, 
as  the  turning  of  the  end  backward  will  result  in  injury  of  the  hyaloid 
membrane  and  prolapse  of  the  vitreous.  When  the  anterior  chamber  is 
reached,  gentle  pressure  is  exerted  on  the  iris,  one  edge  of  the  spatula 


EXTRACTION  OF  SENILE  CATARACT.  139 

being  turned  slightly  posteriorly  at  the  same  time  (Fig.  81).  By  moving 
the  spatula  toward  the  center  of  the  pupil,  the  iris  is  stroked  into  its 
proper  position.  It  is  of  no  importance  which  hand  is  used  in  this 
manipulation.  We  employ  alternately,  as  a  rule,  the  right  and  left  hand 
for  the  right  and  left  angles  of  the  wound,  respectively.  In  many 


FiG.So.  FiG.Si. 

FIG.  80. — Diagram  representing  the  eye  and  spatula  during  the  reposition  in  natural 
size.  For  the  purpose  of  reposition  the  spatula  is  introduced  into  the  angle  of  the  wound 
between  cornea  and  iris. 

FIG.  81. — In  order  to  accomplish  the  backward  stroking  more  easily,  the  spatula  is 
rotated  a  few  degrees  (set  on  edge)  and  then  by  a  suitable  movement  the  angular  extremity 
of  the  sphincter  is  smoothed  down. 

cases  one  can  smooth  the  iris  out  directly  from  above  downward,  by 
holding  the  spatula  in  a  vertical  manner. 

The  proper  position  of  the  conjunctival  flap  is  to  be  considered 
last.  This  should  be  carefully  stroked  into  its  intended  position  by 
aid  of  the  spatula.  Occasionally  the  conjunctival  flap  is  included  in 
the  wound,  which  naturally  causes  a  material  disturbance  in  its  closure. 

After  the  conjunctival  sac  had  been  freed  of  blood  and  lens  rem- 
nants, the  eye  is  closed  and  a  binocular  bandage  applied. 


CHAPTER  XII. 
EXTRACTION  OF  SENILE  CATARACT  (Continued). 

ACCIDENTS  AND  COMPLICATIONS. 

The  foregoing  description  concerns  the  operation  for  extraction 
of  senile  cataract  when  no  undue  incidents  have  occurred.  Untoward 
accidents,  however,  may  complicate  each  stage  of  the  operation,  and 
these  complications  are  described  and  classified  under  the  particular 
stage  of  the  operation  in  which  they  occur. 

1.  Fixation  of  the  eyeball. 

The  conjunctiva  may  be  torn  out.  In  elderly  people  the  conjunctiva 
is  often  very  friable,  and  in  grasping  it  the  forceps  are  likely  to  tear 
out.  In  case  of  this  accident,  if  the  operator  is  already  in  the  midst  of 
the  incision  and  the  patient  does  not  of  his  own  volition  look  downward, 
a  muscle-insertion  must  be  seized  with  the  forceps,  either  that  of  the 
inferior  rectus,  or,  preferably,  of  the  superior  rectus,  the  eye  being  pulled 
somewhat  forward  out  of  the  orbit.  It  would  be  useless  to  seize  the 
conjunctiva  in  another  place,  for  it  would  tear  out  again.  It  is  not 
permissible  to  bring  the  knife  to  a  standstill  while  it  is  in  the  anterior 
chamber,  as  the  aqueous  humor  escapes  and  the  iris  falls  in  the  way  of 
the  knife.  The  only  disadvantage  of  grasping  a  muscle-insertion  lies 
in  the  fact  that  if  the  incision  is  not  yet  commenced,  the  knife  in  the 
act  of  making  the  puncture  causes  a  marked  rolling  of  the  eye,  which 
renders  the  beginning  of  the  cut  somewhat  difficult. 

2.  The  incision. 

The  experienced  operator  rarely  fails  to  get  the  cut  in  the  desired 
position,  while  with  the  beginner  the  opposite  is  often  the  case.  The 
errors  possible  in  regard  to  the  incision  concern:  a.  the  position;  b.  the 
length;  c.  the  manner  in  which  it  is  executed. 

a.  The  incision  may  either  fall  too  far  forward  in  the  cornea,  or  too 
far  backward  from  the  limbus  in  the  sclera.  The  latter  especially 
occurs  when  the  operator  is  a  novice,  and  is  usually  due  to  the  following 
circumstances.  The  puncture  at  the  limbus  is  naturally  quite  easy. 
On  the  contrary,  the  counterpuncture  is  much  more  difficult  on 
account  of  the  already  described  relations  of  the  peripheral  part  of  the 

140 


EXTRACTION  OF  SENILE  CATARACT.  141 

anterior  chamber.  If  the  knife  is  pushed  on  directly  into  the  angle  of 
the  chamber,  the  sclera  is  pierced  in  an  oblique  direction  and  the  knife 
is  seen  to  appear  far  behind  the  limbus  beneath  the  conjunctiva.  In 
order  to  bring  the  knife  out  directly  at  the  limbus,  the  point  should  be 
steered  toward  a  spot  in  the  cornea  about  i  mm.  distance  inward 
from  the  limbus.  The  operator,  looking  at  the  eye  from  in  front, 
thinks  that  the  point  of  exit  will  be  much  too  far  in  the  cornea,  and 
is  surprised  to  see,  in  spite  of  this,  the  point  of  the  knife  appearing 
in  the  limbus  or  close  behind  it.  Hence,  the  novice  may  naturally 
fall  easily  into  the  opposite  error,  of  making  the  counterincision  much 
too  far  into  the  cornea. 

Both  of  these  abnormal  incisions  have  great  disadvantages.  The 
peripheral  incision  in  the  sclera  is  usually  accompanied  by  severe 
hemorrhage,  which  renders  the  operation  exceedingly  troublesome, 
the  more  so  as  the  blood  from  the  wound  situated  higher  up,  continues 
to  flow  into  the  chamber  and  hides  the  iris  and  lens  from  the  operator's 
view.  Besides,  the  incision  is  quite  painful  for  the  patient,  as  the 
cocain  has  not  the  same  effect  on  the  sclera  as  on  the  cornea. 

Because  of  the  position  of  the  peripheral  incision,  the  knife  passes 
through  nearly  in  the  plane  of  the  iris.  This  is  the  reason  why  the 
iris  falls  into  the  way  of  the  knife  and  why  a  large  piece  is  excised, 
the  lens-capsule  being  in  addition  frequently  injuied  at  the  same  time. 
When  we  consider  that  the  patient  in  consequence  of  the  painfulness  of 
the  incision  usually  winces,  we  have  an  explanation  why  this  single 
error  in  making  the  incision,  which  is  so  frequently  seen  in  the  extrac- 
tion by  the  novice,  gives  rise  to  the  common  distressing  experience  of 
wound  of  the  iris  and  lens-capsule — the  lens  protruding  through  the 
gaping  wound,  and  behind  it  the  vitreous  pouring  out. 

Gaping  of  the  wound  is  in  general  one  of  the  great  disadvantages 
of  peripherally  situated  incisions,  particularly  as  it  predisposes  to  an 
extensive  prolapse  of  the  vitreous.  It  may  almost  be  said  that  an 
incision  situated  too  far  forward  in  the  cornea  is  better  than  one  made 
too  far  in  the  sclera,  but  it  also  has  objections,  the  chief  of  which  is  its 
relative  shortness.  The  further  into  the  cornea  the  incision,  the  more 
it  becomes  shortened  from  the  arch  to  its  chord.  The  delivery  of  the 
lens  is  consequently  made  more  difficut.  This  will  be  discussed  further, 
later  on. 

A  high  grade  of  astigmatism  is  another  unpleasant  sequel  of  corneal 
incisions  and  unfortunately  it  may  remain  permanent.  The  formation 


142  OPHTHALMIC    SURGERY. 

of  an  anterior  synechia  is  another  no  less  disagreeable  complication, 
as  the  periphery  of  the  iris  cannot  be  excised,  and  in  consequence 
increase  in  tension  may  follow  by  the  obturation  of  the  angle  of  the 
chamber. 

The  greater  liability  of  the  corneal  wound  to  infection  is  of  less 
significance  nowadays,  since  the  operation  is  performed  under  anti- 
septic precautions. 

b.  The  length  of  the  incision. 

On  an  average  the  incision  should  include  about  a  third  of  the 
corneal  periphery.  No  difficulties  are  presented  in  finding  the  right 
point  of  the  insertion — i  mm.  above  the  end  of  the  horizontal  meridian. 
Only  through  an  abnormally  oblique  passage  of  the  knife  through  the 
anterior  chamber,  an  improperly  situated  counterpuncture  can 
result,  in  consequence  of  which  the  cut  will  be  too  short.  The 
relative  shortness  of  a  corneal  incision  has  already  been  mentioned. 
The  type  of  patient  must,  however,  be  always  taken  into  consideration 
in  determining  the  length  of  the  incision.  If  a  comparatively  young 
individual  (in  the  early  forties),  in  all  probability  a  shorter  incision 
will  suffice,  as  at  this  age  the  lens  nucleus  is  still  small.  Greater  length 
of  the  incision  at  the  very  outset  is  to  be  considered,  if  a  large  brown 
cataract,  a  totally  sclerosed  lens,  is  present.  Should  the  patient 
have  an  abnormally  small  cornea,  the  incision  must  be  begun  further 
below,  if  necessary  at  the  horizontal  meridian,  to  insure  a  diameter 
of  sufficient  size. 

c.  The  manner  of  performing  the  incision  deserves   a   special 
discussion.     The  first  rule  to  be  observed  is  under  no  circumstances 
to  withdraw  the  knife  after  it  has  once  pierced  the  outer  tunic  of  the 
eye  and  entered  the  anterior  chamber.     The  beginner,  becoming  fright- 
ened at  seeing  the  knife  pierce  a  small  bit  of   iris,  draws  the  knife 
backward  in  order  to  free  it.     The  immediate  result  is  escape  of  the 
aqueous  humor,  and  instead  of  a  small  piece,  the  whole  width  of  the 
iris  must  now  be  cut  through.     It  is  never  permissible  to  draw  the 
knife  backward,   nor  even  bring  it  to   a  standstill.     The   counter- 
puncture  once  completed,  no  delay  is  allowable,  and  the  incision  is  to 
be  continued  immediately. 

If  it  should  happen  that  the  anterior  chamber  has  been  entered  with 
the  edge  of  the  knife  directed  downward,  the  counterpuncture  is  first 
to  be  made,  and  then  the  knife  rotated  as  quickly  as  possible  180°  in  its 
long  axis,  so  that  its  edge  becomes  directed  upward.  The  quick  rotation 


EXTRACTION  OF  SENILE  CATARACT.  143 

]  in- vents  the  escape  of  the  aqueous  humor.  Turning  of  the  knife  in 
the  wound  is  without  disturbing  consequences,  if  its  edge  passes  the 
arch  in  the  direction  toward  the  cornea. 

In  making  the  puncture,  if  the  knife  is  held  with  its  point  directed 
too  far  forward,  it  may  happen  that,  instead  of  entering  the  anterior 
chamber  at  once,  the  blade  courses  between  the  lamellae  of  the  cornea 
for  some  distance — the  so-called  intralamellar  incision.  This 
error  results  in  a  wound  much  too  small.  An  intralamellar  incision  is, 
however,  rare  in  the  cataract-operation,  as  the  anterior  chamber  is 
usually  deep  and  the  operator  has  no  fear  of  piercing  the  limbus  per- 
pendicularly, as  in  the  operation  for  glaucoma,  where  the  danger  of 
injuring  the  lens  is  always  present.  If  the  improper  direction  of  the 
knife  between  the  lamellae  of  the  cornea  is  noticed  early  enough,  that 
is,  before  a  puncture  into  the  anterior  chamber  has  resulted  in  escape 
of  the  aqueous,  the  knife  can  be  withdrawn  and  the  incision  repeated 
at  once  in  the  correct  place.  If  the  aqueous  humor  has  already  escaped, 
the  operator  must  continue  with  the  incision,  no  matter  how  it  termin- 
ates, and  eventually  widen  it  later  with  the  scissors. 

The  surface  of  the  knife  blade  must  always  be  parallel  to  the 
surface  of  the  iris.  Only  in  this  way  is  it  possible  to  continue  cutting 
in  the  same  plane.  Should  the  edge  of  the  knife  be  turned  slightly 
forward,  the  incision  deviates  anteriorly  into  the  cornea;  if  directed  a 
trifle  backward,  it  is  made  more  and  more  obliquely  into  the  sclera. 

No  direct  pressure  should  be  made  with  the  knife ;  on  the  con- 
trary, the  blade  is  to  be  drawn  through  in  an  upward  direction  with 
long  sawing  movements.  Pressure  of  the  knife  against  the  sclera, 
stops  its  forward  progress.  Thus  a  novice  may  believe  that  he  has  a 
dull  knife,  while  he  himself  is  responsible  for  the  poor  incision. 

The  knife  should  be  carried  through  the  chamber  in  a  hori- 
zontal direction.  While  it  is  lightly  held  between  the  thumb  on  one 
side,  and  fore-  and  middle  fingers  on  the  other,  the  handle  of  the  knife 
rests  upon  the  first  joint  of  the  forefinger.  The  little  finger  is  supported 
in  the  region  of  patient's  temple  to  prevent  making  a  false  cut,  should 
he  move  unexpectedly. 

After  the  sclera  has  been  cut  through,  and  the  knife  is  beneath  the 
conjunctiva,  it  is  turned  so  as  to  cause  the  edge  to  look  anteriorly.  It 
is,  however,  an  error,  to  turn  the  knife  while  it  is  still  embedded  in 
the  sclera,  as  not  merely  irregularity  in  the  wound  will  occur,  but  the 
incision  will  lie  in  a  false  position,  too  far  into  the  cornea. 


144  OPHTHALMIC    SURGERY. 

Finally,  there  is  to  be  considered  which  hand  should  make  the 
incision?  To  operators  who  are  not  naturally  lefthanded,  the  cut 
made  with  the  left  hand  does  not  present  any  unusual  difficulties. 

The  surgeon  who  only  employs  the  right  hand  must  operate  on  the 
right  eye  from  behind,  and  on  the  left  eye  from  in  front.  There  are 
operators  who  always  operate  from  behind,  and  who,  for  that  reason, 
must  use  the  right  and  left  hand  alternately.  The  great  objection  to 
this  position  is  that  the  surgeon  must  bend  over  the  patient,  a  circum- 
stance which  certainly  is  not  favorable  for  proper  asepsis  of  the  wound. 

3.  Performance  of  the  Iridectomy. 

The  first  complication  to  present  itself  during  this  step  of  the  opera- 
tion may  be  hemorrhage.  If  the  incision  bleeds  considerably,  the 
blood  in  the  anterior  chamber  obscures  the  view,  so  that  one  has  to 
seize  the  iris  without  seeing  it.  The  actual  cutting  of  the  iris  is  usually 
not  especially  painful,  as  the  cocain  has  a  sufficient  anesthetic  effect. 

The  iridectomy  is  beset  with  difficulties  if  an  intractable  patient 
does  not  look  down,  or  looks  up  or  aimlessly  around,  and  it  may 
be  impossible  to  seize  the  iris  with  the  forceps.  One  may  then  draw  it 
forward  with  a  blunt  hook,  bent  in  a  proper  manner,  and  do  the  exci- 
sion. We  fix  the  eye  with  the  forceps  only  with  great  unwillingness  and 
only  in  case  of  absolute  necessity  while  doing  an  iridectomy,  as  the 
fixation  invariably  causes  the  wound  to  gape. 

An  unpleasant  accident  which  may  happen  in  iridectomy  is  the  pro- 
duction of  an  iridodialysis.  If,  after  the  iris  has  been  seized  with  the 
forceps,  the  patient  suddenly  moves  his  eye  or  head,  unless  the  operator 
is  quick  enough  to  release  the  iris,  there  may  ensue  a  separation  of 
the  iris  at  its  ciliary  margin  to  a  greater  or  lesser  extent.  As  a  rule  a 
considerable  hemorrhage  occurs  directly  after,  which  greatly  adds  to 
the  difficulties  of  further  operating. 

Should  the  iris  during  the  incision  fall  into  the  way  of  the  knife, 
a  broad  piece  is  usually  cut  out,  which  prolapses  into  the  wound.  If 
the  prolapse  shows  in  the  incision  at  once,  it  requires  only  removal  with 
the  forceps.  In  other  cases  it  must  be  removed  from  the  anterior 
chamber.  Only  when  it  is  still  connected  in  one  place  with  the  rest 
of  the  iris,  it  has  to  be  excised  at  that  point. 

If  only  the  periphery  of  the  iris  falls  into  the  way  of  the  knife,  a 
bridge-shaped  coloboma  is  formed,  in  which  a  more  or  less  wide  portion 
of  the  pupillary  margin  persists.  It  is  not  necessary  to  draw  it  up 
and  cut  it  off.  Sometimes  a  narrow  sphincter  bridge  cannot  be 


EXTRACTION  OF  SENILE  CATARACT.  145 

caught  with  the  forceps,  so  that  one  has  to  resort  to  the  blunt  hook  to 
pull  it  out.  If  the  bridge  is  permitted  to  remain,  it  may  either  persist 
unharmed  during  the  delivery  of  the  lens,  the  nucleus  passing  through 
the  coloboma,  or  it  may  tear  away. 

4.  Opening  the  capsule. 

In  spite  of  the  somewhat  more  difficult  manipulation  of  the  capsule- 
forceps,  we  usually  prefer  them  to  the  cystotome,  and  only  in  certain 
selected  cases  use  the  sharp  tenaculum.  As  that  portion  of  the 
anterior  capsule  which  corresponds  to  the  pupil,  presents  an  obstacle 
to  vision,  it  is  naturally  better  to  remove  it.  The  extensive  absorption 
of  the  remnants  of  the  lens  in  the  presence  of  a  large  opening  in  the 
capsule  has  already  been  alluded  to.  However,  there  are  circumstances 
in  which  the  use  of  the  forceps  is  objectionable.  If  the  anterior  cham- 
ber is  filled  with  blood,  and  the  boundaries  of  the  pupil  cannot  be  seen, 
the  use  of  the  capsule-forceps  is  likely  to  be  dangerous,  and  by  mis- 
chance a  fold  of  the  iris  might  easily  be  grasped  by  mistake  and  pulled 
out.  In  restless  patients  it  is  preferable  to  resort  to  the  cystotome 
tenaculum.  If  the  pupil  is  narrow,  it  may  also  be  desirable  to  open 
the  capsule  with  the  tenaculum  in  an  extraction  without  iridectomy, 
to  avoid  a  possible  seizure  of  the  iris  by  the  forceps. 

The  employment  of  the  capsule-forceps  will  be  influenced  to  a 
considerable  extent  by  the  condition  of  the  capsule  when  dealing  with  a 
greatly  distended  cataract,  and  a  hypermature,  complicated  cata- 
ract with  thickened  capsule.  If  the  lens  is  so  swollen  that  the  capsule 
is  tense,  a  fold  of  it  cannot  be  lifted  up  with  the  forceps,  except  by 
exerting  more  force  than  is  permissible.  If  the  operator  feels  that  he" 
cannot  grasp  a  fold  of  capsule  between  the  teeth  of  the  forceps  by 
gentle  pressure,  he  should  effect  the  opening  by  the  aid  of  the  tenaculum 
as  too  much  force  will  cause  a  prolapse  of  the  vitreous. 

Should  the  capsule  be  thickened,  great  care  is  demanded  in  the 
use  of  the  forceps.  It  is,  of  course,  an  advantage  to  remove  the 
thickened  anterior  capsule  from  the  pupillary  area,  especially  if  it 
occupies  the  whole  extent  of  the  latter,  as  the  dense  membrane  seriously 
impairs  vision.  In  using  the  forceps  it  may  happen  that  the  thickened 
capsule  offers  more  resistance  than  does  a  defective  zonula;  the  fibers 
of  the  latter  tear  through  and  the  whole  lens  in  its  envelope  is  with- 
drawn from  the  eye.  In  any  event  the  operator  must  be  prepared  to 
assist  in  the  exit  of  the  lens  by  a  downward  pressure  on  the  scleral 
wound-margin  at  the  moment  he  sees  the  whole  lens  yielding.  This  is 


146  OPHTHALMIC    SURGERY. 

done  in  order  to  remove  the  obstacle  presented  by  the  sclera,  so  that 
the  capsule  may  not  finally  rupture  and  leave  the  half-luxated  lens 
behind  in  the  eye.  If  the  patient  is  quiet  and  the  vitreous  of  normal 
consistency,  a  prolapse  of  the  latter  does  not  of  necessity  accompany 
the  extraction  of  the  intact  capsule.  Sometimes  such  prolapse  cannot 
be  avoided.  Should  extraction  with  the  capsule  succeed,  the  terminal 
result  is  excellent,  as  the  pupil  is  free  of  all  remnants  of  tissue. 

It  is  perhaps  superfluous  to  state  that  the  pressure  to  be  exerted  on 
the  lens  with  forceps  in  opening  the  anterior  capsule  must  be  gentle  in  all 
instances.  A  luxation  of  the  lens  backward  into  the  vitreous  could 
possibly  follow  excessive  pressure  with  the  instrument. 

5.  Expression  of  the  cataract. 

The  manner  in  which  pressure  is  to  be  made  on  the  eyeball  to  effect 
exit  of  the  lens  has  already  been  described.  If  the  operator  does  not 
exert  it  against  the  lower  part  of  the  lens,  but  instead  presses  too  high 
up,  perchance  against  the  middle  of  the  cornea,  he  will,  of  course,  wait 
in  vain  for  the  appearance  of  the  lens  in  the  wound.  However,  in  spite 
of  pressure  made  in  the  proper  manner  and  with  a  proper  degree  of 
force,  the  lens-nucleus  may  fail  to  appear  in  the  wound  and  make  its 
exit.  This  is  a  most  critical  moment  for  the  operator,  and  here  he  must 
think  right  and  act  quickly,  well  mindful  of  his  purpose. 

The  causes  of  such  a  contingency  are  as  follows: 

a.  The  wound  may  be  too  small.  If  the  operator  has  begun  the 
incision  too  high  up,  or,  after  an  accurate  puncture,  has  wrongly  made 
the  counterpuncture  too  far  above,  a  relatively  short  incision  is  the 
consequence. 

If  it  is  seen  that  the  lens-nucleus  is  pressing  against  the  wound  but  can 
not  make  its  way  through,  the  incision  must  be  prolonged  either  at  one 
or  both  ends,  with  a  small  pair  of  curved  blunt  scissors,  one  blade  of 
which  is  carefully  pushed  into  the  angle  of  the  chamber  between  the 
cornea  and  iris,  while  the  other  blade  remains  on  the  outside  of  the 
eyeball.  If  shortness  of  the  incision  is  the  real  cause  that  prevents  the 
proper  delivery  of  the  lens,  the  latter  easily  slips  out  of  the  eyeball 
after  the  cut  has  been  enlarged. 

It  may  be,  however,  that  though  the  incision  is  sufficiently  long,  the 
lens-nucleus  may  be  exceptionally  large.  On  this  account,  in  cases 
of  black  cataract,  the  incision  should  be  made  larger  than  usually  at 
the  beginning  of  the  operation.  A  cut  which  is  too  short,  because  made 
too  jar  into  the  cornea,  presents  still  another  factor  which  may 


EXTRACTION  OF  SENILE  CATARACT.  147 

hinder  the  exit  of  the  lens.  The  further  the  incision  in  the  cornea  is 
removed  from  the  limbus,  the  more  must  the  edge  of  the  lens  rotate 
forward  to  present  in  the  wound.  That  is,  the  greater  the  force  which 
the  operator  must  exert  on  the  eye,  the  more  danger  there  is  of  prolapse 
of  the  vitreous.  Therefore,  the  only  thing  to  do  to  facilitate  the  extru- 
sion of  the  lens  is  to  prolong  the  incision  by  making  lateral  cuts  along 
the  limbus,  and  the  same  procedure  is  indicated  if  itXis  too  short,  on 
account  of  being  made  for  some  distance  between  the  corneal  lamella. 

b.  The   sphincter  may   offer   too  great  resistance.     This  will 
be  discussed  when  describing  extraction  without  iridectomy. 

c.  The   anterior    lens-capsule  may  not    have   been    opened. 
The  operator  who  can  see  the  fold  which  his  forceps  have  raised  in 
opening  the  capsule,  or  has  at  least  convinced  himself  of  the  presence 
of  a  piece  of  the  membrane  between  the  branches  of  the  forceps  after 
they  are  withdrawn,  will  always  feel  safe  against  this  error.     If  he  is 
not  certain  of  having  sufficiently  opened  the  capsule,  he  should  intro- 
duce the  forceps  a  second  time  or  have  recourse  to  the  cystotome. 

d.  A  fourth  possible  causative  factor  is  dislocation  of  the  lens, 
usually  a  slight  subluxation  upward.     This  may  be  due  to  traction 
of  the  forceps  on  the  capsule,  to  pulling  too  strongly  on  the  tunics  of 
the  eyeball  during  the  incision,  or  to  the  initial  pressure  having  been 
exerted  in  a  direction,  which  pushed  the  lens  slightly  upward  instead  of 
rotating  it  about  its  horizontal  axis.     Consideration  of  the  associate 
physical  conditions  renders  clear  the  impossibility  of  delivering  the  lens. 
The  pressure  made  by  the  finger  naturally  falls  only  on  the  vitreous,  and 
has  no  longer  any  influence  on  the  position  of  the  lens.    The  latter  does" 
not  rotate  its  margin  into  the  wound,  and  the  operator  who  thinks  to 
accomplish   this  purpose  by  increasing  the  pressure  simply  forces  the 
vitreous  into  the  opening,  at  the  same  time  completely  luxating  the  lens 
backward.     The  removal  of  the  lens  can  then  only  be  accomplished  by 
returning  it  to  its  original  position,  which  may  be  obtained  by  introducing 
a  spatula  into  the  anterior  chamber  and  bringing  the  instrument  into 
contact  with  the  anterior  surface  of  the  lens,  pushing  it  downward  into 
its  normal  position.      After  this  maneuver  the  expression  of  the  lens 
is  at  once  obtained  by  pressure  exerted. 

If  the  lens  becomes  luxated  in  any  direction  other  than  upward, 
for  example,  internally  or  externally,  it  must  be  treated  as  described 
elsewhere. 

When  the  lens-nucleus  has  become  considerablv  diminished  in 


148  OPHTHALMIC    SURGERY. 

size,  its  exit  may  also  be  more  difficult,  as  is  frequently  seen  in  compli- 
cated cataract  and  invariably  in  over-ripe  cataract  (Morgagnian  cata- 
ract). One  understands  that  the  employment  of  pressure,  in  the 
manner  just  described,  is  absolutely  useless,  if  the  lens  is  not  normal 
in  position  and  size.  If  the  cortical  substance  has  liquefied  and  pours 
out  after  the  anterior  lens-capsule  has  been  opened,  the  small  nucleus 
either  sinks  down  to  the  bottom  of  the  capsule-sac  or  is  carried  slightly 
upward  behind  the  iris  by  the  escaping  cortical  matter.  In  neither  of 
these  two  instances  is  it  possible  through  the  regular  expression  to 
influence  the  position  of  the  lens-nucleus.  Pressure  is  absolutely  con- 
traindicated.  If  the  lens  lies  far  down,  it  may  be  gradually  worked 
upward  by  gentle  stroking  movements,  and  finally  brought  out  of 
the  wound  with  Daviel's  spoon.  If,  however,  it  has  been  pushed 
up  behind  the  iris,  it  must  be  first  stroked  down  by  means  of  the  spoon 
into  the  pupil  and  from  there  guided  upward  out  of  the  wound. 

6.  Prolapse  of  the  vitreous  is  the  most  unpleasant  of  accidents, 
and,  although  it  does  not  usually  occur  until  during  the  act  of  expressing 
the  cataract,  it  may  happen  in  any  of  the  stages  of  the  operation.  It  is 
of  less  significance  when  it  ensues  after  the  removal  of  the  lens,  and 
that  time  it  is  best  to  do  nothing  further  than  make  sure  that  the  corneal 
flap  remains  in  its  proper  position,  and  is  not  bent  forward  through 
the  pressure  which  the  vitreous  exerts  from  behind.  To  undertake  a 
reposition  of  the  iris  is  not  advisable,  as  by  doing  so  there  would  only 
be  caused  further  protrusion  of  the  vitreous.  The  best  procedure,  there- 
fore, is  to  close  the  patient's  eye  immediately  the  vitreous  appears,  the 
upper  lid  being  carefully  guided  over  the  flap  with  the  assistance  of  the 
spoon  held  beneath  the  lid.  As  the  protrusion  of  the  vitreous  causes 
pain,  the  patient  usually  winces,  which  may  cause  still  more 
vitreous  to  be  pressed  out  of  the  eye.  Moreover,  it  is  easily  possible 
for  the  upper  lid  to  fall  into  the  open  wound  and  to  turn  the  flap 
forward.  This  accident  will  be  discussed  more  fully  when  speaking  of 
the  duties  of  the  assistant  during  the  cataract-operation  (p.  237). 

After  the  patient  has  closed  the  eye,  the  upper  lid  is  slightly  raised 
with  great  care  (best  by  means  of  the  eyelashes)  and  at  the  same  time 
the  lower  lid  is  drawn  away  from  the  eye.  The  position  of  the  flap 
behind  the  upper  lid  may  then  be  inspected,  and,  if  necessary,  is 
smoothed  out  by  a  spatula.  After  this,  the  patient  should  not  be 
allowed  to  open  his  eye  and  for  this  reason  it  is  of  advantage  to  keep 
the  other  eye  also  closed  by  a  bandage. 


EXTRACTION  OF  SENILE  CATARACT.  149 

When  the  vitreous  appears  prior  to  the  removal  of  the  lens, 

the  accident  naturally  becomes  much  more  troublesome.  If  the  iris 
has  not  as  yet  been  excised,  an  iridectomy  can  only  be  performed  if  the 
iris  has  been  so  floated  into  the  wound  by  the  vitreous  that  it  can  be 
seized  readily  by  the  forceps  and  cut  out.  If,  however,  the  iris  has 
not  fallen  forward,  any  attempt  to  seize  it  with  the  forceps  must  be  hope- 
less, as  the  instrument  picks  up  only  the  vitreous,  never  the  iris,  which 
had  been  pushed  backward  toward  the  ciliary  body,  so  that  a  large 
coloboma  upward  is  to  be  seen. 

Expression  of  the  cataract  after  appearance  of  the  vitreous 
is  impossible,  since  every  time  that  pressure  is  made  a  further  pro- 
lapse occurs.  Instead,  extraction  of  the  lens  in  its  capsule  must 
be  resorted  to,  and  for  this  purpose,  either  a  loop  (Weber's)  or  a 
double  tenaculum  (Reisinger's)  is  employed,  the  manipulation  of 
the  former  being  easier  for  the  beginner. 

The  loop,  (Fig.  82)  directed  obliquely  back-ward  (Fig.  83),  is 
introduced  through  the  wound,  until  it  reaches  a  position  in  the  mid- 
dle of  the  vitreous  and  about  opposite  the  posterior  pole  of  the  lens. 
It  is  then  turned  forward  in  such  a  way  (Figs.  84  to  87)  that  the 


FIG. 82  . — Weber's  loop. 

lens  is  pressed  against  the  posterior  aspect  of  the  cornea  and  glides  out 
between  the  cornea  and  the  instrument;  in  other  words,  it  is  lifted  out 
of  the  eye  by  the  loop. 

Reisinger's  double  tenaculum  (Fig.  87)  is  inserted  closed  into  the 
vitreous  area  in  a  manner  similar  to  that  used  in  introducing  the  loop, 
in  order  that  the  points  of  the  tenaculum  may  not  become  entangled  in 
the  edges  of  the  wound,  the  instrument  is  held  with  the  plane  of  the 
bent  portion  parallel  to  the  wound,  therefore,  in  a  frontal  direction. 
Not  until  the  instrument  is  found  to  be  behind  the  middle  of  the  lens, 
is  ]it  rotated  about  90  °  on  its  long  axis,  so  that  the  points  are  now  di- 
rected forward.  The  two  arms  are  then  permitted  to  separate  and  sink 
into  the  posterior  surface  of  the  lens,  which  is  now  pressed  against  the 
posterior  aspect  of  the  cornea  and  in  this  manner  withdrawn  from  the 
eye.  This  instrument,  therefore,  can  only  be  used  when  a  firm  lens- 


OPHTHALMIC    SURGERY. 


nucleus  is  present.     If  the  nucleus  is  soft,  the  loop  is  recommended,  as 

the  tenaculum  would  cut  through  the  soft  mass  without  bringing  it  out. 

Both  the  instruments  must  be  carried  backward  into  the  vitreous 

in  an  oblique  manner,  for  the  reason  that  if  held  vertically,  they  would 


a 


FIG.  83. — Introduction  of  Weber's  loop  in  case  of  escape  of  vitreous  prior  to  the  delivery 
of  the  lens.  The  loop  is  directed  backward  through  the  gaping  wound  behind  the  lens 
into  the  vitreous.  The  assistant  holds  the  upper  lid  well-fixed  with  the  thumb  of  the  right 
hand  and  has  the  spoon  in  the  left  hand  ready,  after  the  extraction  has  been  completed,  to 
guide  the  upper  lid  down  over  the  gaping  wound.  The  operator  himself  fixes  the  lower  lid. 

push  against  the  margin  of  the  lens  and  produce  a  luxation  into  the 
vitreous.  During  the  entire  manipulation,  the  lids  must  be  drawn 
away  from  the  eye,  so  that  they  can  exert  no  pressure  on  the  globe. 


EXTRACTION  OF  SENILE  CATARACT. 


The  upper  lid  is  best  raised  by  means  of  a  Desmarres  spoon.  In  every 
cataract-operation  the  loops  and  tenaculum  should  be  kept  near  at 
hand  and  sterilized,  as  prolapse  of  the  vitreous  occasionally  takes 


FIG  84. — Second  step  of  this  procedure.  The  loop  has  been  placed  upright  in  such  a 
fashion  as  to  press  the  lens  against  the  posterior  aspect  of  the  cornea  and  can  now  be  drawn 
along  the  latter  and  out  of  the  eye. 

place  in  operations  in  which  a  completely  normal  course  had  been 
expected. 

Generally  speaking,  the  greater  the  dexterity  of  the  operator,  the 
rarer  will  be  prolapse  of  the  vitreous  in  uncomplicated  cataract.  Severe 
straining,  holding  the  breath,  etc.,  on  the  part  of  the  patient  may  be 
responsible  for  the  accident,  while  the  surgeon  may  induce  the  prolapse 


152 


OPHTHALMIC    SURGERY. 


by  undue  pressure  on  the  eye  with  the  forceps  during  the  incision,  in 
delivery  of  the  lens,  or  in  scraping  out  the  lens-remnants.  Quite 
unavoidable  often  is  the  prolapse  in  the  presence  of  complicated  cata- 
racts, when  the  zonula  is  destroyed,  or  the  vitreous  has  lost  its  normal 
consistency. 

Prolapse  of  the  vitreous  is  the  most  serious  complication  in 
the  operation  for  cataract-extraction,  and  it  is  absolutely  necessary  to 
recognize  at  the  right  time  whether  a  prolapse  is  imminent,  and  if  so, 
to  prevent  it  if  possible. 


FIG.  85.  FIG.  86. 

FIG.  85. — Diagrammatic  representation  of  the  introduction  of  the  loop.  The  loop  is 
directed  backward  in  an  oblique  manner. 

FIG.  86. — The  loop  is  raised  up  and  the  lens  pressed  against  the  posterior  wall  of  the 
cornea. 


Several  phenomena  are  associated  with  this  complication: 
i.  Very  characteristic  is  the  forward  bulging  through  the  pupil  and 
coloboma  of  the  vitreous  with  the  hyaloid  membrane  still  unruptured. 
If  after  the  expression  of  the  lens-nucleus,  the  pupil  and  coloboma  are 
filled  with  greyish  lens-remnants  which  suddenly  separate  at  one  point, 
and  the  pupil  in  this  locality  becomes  a  deep  black,  we  have  the  first 
sign  that  the  vitreous,  still  contained  within  its  uninjured  membrane, 
has  pushed  forward  and  penetrated  the  tissues  in  front.  Only  the 
inexperienced  operator  will  continue  to  exert  pressure  to  remove  the 
remaining  lens-particles,  for  the  rupture  of  the  hyaloid  membrane 


EXTRACTION  OF  SENILE  CATARACT.  153 

would  occur  the  next  moment.  It  is  better  to  be  satisfied  with  care- 
fully stroking  back  the  iris,  and  even  this  is  only  possible  if  the  patient 
remains  correspondingly  quiet,  but  it  often  becomes  displaced  again 
through  the  vitreous  pushing  forward. 

2.  The  same  bulging  forward  of  the  vitreous  in  the  unruptured  hya- 
loid membrane  may  also  occur  with  a  simultaneous  marked  deepening 
of  the  anterior  chamber.     A  hernia  of  the  vitreous  presses  at  the 
same  time  through  the  pupil  into  the  anterior  chamber,  filling  it  out  and 
pushing  back  the  iris. 

3.  Another  characteristic  sign  is  the  deepening  of  the  anterior 
chamber  in  consequence  of  the  accumulating  vitreous,  which  is  already 
poured  in  through  a  rupture  in  the  hyaloid  membrane.     This  is  natur- 
ally followed  at  once  by  an  outflow  of  the  vitreous  through  the  wound. 
The  first  indication  of  the  vitreous  flowing  into  the  anterior  chamber 
is  occasionally  manifested  by  changes,   which  the  blood  undergoes 


FIG.  87. — Reisinger's  double  tenaculum. 

through  coming  into  contact  with  the  vitreous.  It  coagulates  into 
thread-like  clots  becoming  lighter  in  color. 

Deepening  of  the  anterior  chamber  may  also  be  produced  by  the 
entrance  of  air,  but  as  the  air-bubble  is  always  clearly  seen,  it  cannot 
be  confounded  with  the  appearance  just  described  as  due  to  the  vitre- 
ous. The  air  in  itself  is  not  harmful,  but  it  may  so  disturb  the  appa- 
rent relations  of  the  anterior  chamber,  especially  the  position  of  the 
margins  of  the  iris,  that  an  attempt  should  be  made  to  remove  it  from 
the  eye  by  massage.  As  the  air  is  easily  sucked  in  again,  this  measure 
is  usually  valueless. 

4.  If  the  lens  is  still  in  the  eye,  the  tendency  to  vitreous-prolapse  is 
indicated  by  a  turning  up  of  the  edges  of  the  wound,  and  in  conse- 
quence the  wound  gapes.  While  vitreous-prolapse  may  sometimes 
be  caused  by  the  patient  holding  his  breath  or  straining  down,  in  other 
cases  no  cause  can  be  found,  the  prolapse  occurring  unexpectedly. 
Especially  during  peripheral  incisions  the  hyaloid  membrane  may 
rupture  in  the  region  of  the  wound,  and  the  vitreous  extrude  through 
the  widely  gaping  wound,  without  any  previous  sign  whatever  having 
been  noticed  in  the  anterior  chamber. 

If  the  vitreous  is  perfectly  fluid,  it  will  ooze  steadily  from  the  eye 


154  OPHTHALMIC    SURGERY. 

immediately  after  the  incision,  without  any  gaping  of  the  wound. 
Great  loss  of  fluid  is  only  recognized  by  collapse  of  the  eyeball. 
As  this  precludes  regular  extraction  of  the  lens,  the  loop  or  tenaculum 
must  be  resorted  to.  On  the  whole,  the  loss  of  perfectly  fluid  vitreous 
is  in  general  much  better  tolerated  than  the  loss  of  the  normal  vitreous. 
In  a  few  hours  it  is  replaced  by  new  fluid,  which  returns  the  eye  to  its 
normal  state  of  tension.  As  the  wound  does  not  gape,  it  heals  smoothly ; 
whereas,  in  the  loss  of  normal  vitreous,  the  cicatrix  remains  ectatic  for 
a  long  time. 

In  the  rare  instances  in  which  the  protruding  vitreous  constantly 
turns  the  corneal  flap  forward,  and  it  cannot  be  retained  in  its  proper 
position  by  stroking  it  back  with  the  spatula,  nothing  remains  to  be 
done  except  to  fasten  it  wTith  two  or  more  silk  sutures. 

When  the  dressings  are  changed  on  the  day  after  the  operation,  it 
may  be  found  that  the  corneal  flap  is  turned  downward.  This 
is  caused  by  the  patient  with  a  gaping  wound  opening  the  eye  beneath 
the  bandage,  so  that  the  upper  lid  in  closing  enters  the  wound.  After 
instilling  cocain-solution  the  flap  must  be  carefully  stroked  upward 
and  brought  into  its  proper  position.  If  no  infection  ensues,  which, 
however,  is  a  likely  result,  the  eye  need  not  be  considered  as  lost.  For 
a  long  time  a  straight  white  line  is  retained  as  a  sign  of  the  corneal  injury. 

The  sequelae  of  prolapse  of  the  vitreous  may  in  all  cases  be  seri- 
ous. A  replacement  of  the  iris  is  impossible,  and,  therefore,  an  attach- 
ment of  its  margins  to  the  wound  is  a  usual  occurrence,  in  consequence 
of  which  cystic  scars,  glaucoma,  and  signs  of  irido-cyclitic  irritation 
often  appear.  Hemorrhage  into  the  open  vitreous  chamber  may  lead 
to  marked  opacities  which  later  are  seen  as  free  floating  membranes 
or  hang  into  the  vitreous  chamber  from  the  point  of  attachment. 
Detachment  of  the  retina  occurs  only  after  great  loss  of  vitreous 
except  in  an  eye  especially  predisposed  (myopia,  etc.). 

Several  other  accidents  during  the  cataract  operation  must 
be  mentioned. 

The  lens  may  be  displaced  back  into  the  vitreous  chamber, 
either  spontaneously  or  through  the  unskillful  manipulation  of  the 
operator.  In  such  case  any  attempt  to  recover  it  is  useless  and  results 
only  in  further  injury  to  the  eye.  The  operation  has  to  be  stopped 
and  the  eye  bandaged.  Iridocyclitis  often  follows  this  accident. 

The  so-called  collapse  of  the  cornea,  which  is  occasionally  met 
with  during  the  operation  for  cataract,  is  of  absolutely  no  importance. 


EXTRACTION  OF  SENILE  CATARACT.  155 

Immediately  after  completing  the  incision,  or  after  expression  of  the 
lens,  the  cornea  sinks  down  so  that  a  depression  appears.  This  hap- 
pens in  softened  eyes,  and  when  the  cornea  is  flabby,  especially  in  old 
people,  whose  cornea  is  often  extremely  atrophic. 

Expulsive  hemorrhage  is  fortunately  an  infrequent  complication. 
It  may  occur  during  the  course  of  the  operation,  but  usually  appears 
suddenly  several  hours  afterward;  it  is  seen  not  only  aftei  extraction 
complicated  by  the  loss  of  the  vitreous,  but  also  following  operations 
with  a  perfectly  normal  course.  The  hemorrhage  is  retrochorioideal 
and  is  so  extensive  that  the  vitreous,  chorioid  and  the  retina  are  driven 
outward  through  the  wound.  Immediate  enucleation  spares  the 
patient  a  long  period  of  suffering.  Unfortunately,  we  have  no  means 
to  prevent  this  accident;  indeed,  we  do  not  even  know  of  a  single  symp- 
tom which  will  afford  warning  of  the  danger  before  the  operation. 
As  associated  factors  the  following  must  be  taken  into  consideration: 
the  sudden  lowering  of  the  intraocular  pressure  caused  by  the  operation; 
the  rigidity  of  th?  external  tunic  of  the  eye;  arteriosclerosis  and  the  con- 
comitant tendency  of  the  blood-vessels  to  rupture;  and  increase  in  blood- 
pressure  occurring  during  the  operation  on  account  of  the  increased 
activity  of  the  heart  due  to  the  excitement  of  the  patient.  To  at  least 
exclude  the  last  factor,  Fuchs  gives  those  patients  who  have  lost  one 
eye  through  an  expulsive  hemorrhage,  a  large  dose  of  bromids  before 
the  operation  (two  grams).  The  danger  that  hemorrhage  may  follow 
extraction  of  a  cataract  from  the  other  eye  is  not  sufficiently  great  to 
warrant  the  operator  in  performing  a  depression  of  the  cataract  into  the 
vitreous  humor  after  the  old  method  instead  of  the  usual  extraction. 
Here  it  may  be  mentioned  that  we  do  not  perform  preliminary  iri- 
dectomy,  either  in  unripe  or  complicated  cataract,  it  having  no  special 
advantage;  on  the  contrary,  it  adds  to  the  danger  of  a  second  operation. 

EXTRACTION  WITHOUT  IRIDECTOMY. 

Apart  from  the  cosmetic  standpoint  there  is  no  sound  argument  that 
can  be  advanced  in  favor  of  the  operation  without  iridectomy.  On  the 
contrary,  this  method  possesses  several  disadvantages,  which  must  not 
be  underestimated.  Prominent  among  these  are  the  necessity  of  a 
second  operation  in  case  of  subsequent  prolapse  of  the  iris,  and  the 
increase  in  pressure  caused  by  the  occasional  distortion  and  fixation  of 
the  iris  to  the  scar. 

Indications. — This  operation  may  be   performed  if   it  is  certain 


156  OPHTHALMIC    SURGERY. 

that  the  patient  will  lie  quietly  in  bed  afterward;  hence,  it  should 
never  be  undertaken  in  very  old  people  or  if  the  patient  has  a  cough. 
If  there  is  good  vision  in  the  other  eye,  extraction  without  iridectomy 
may  sometimes  be  permissible.  If,  however,  the  other  eye  is  incapaci- 
tated or  its  vision  diminished  in  consequence  of  some  disease  apart 
from  incipient  cataract,  the  extraction  must  always  be  performed  with 
iridectomy  so  as  to  avoid  any  complications.  To  be  successful,  extrac- 
tion without  iridectomy  further  depends  upon  certain  conditions  of  the 
eye.  With  a  narrow  pupil  and  a  large  lens-nucleus,  it  is  readily  under- 
stood that  the  operation  must  be  done  with  an  iridectomy;  the  same  is 
true  in  all  cases  of  complicated  cataract.  Therefore,  it  is  only  when 
the  iris  tends  to  retain  its  position  in  the  eye  and  shows  no  inclination 
to  fall  forward,  and  the  course  of  the  operation  promises  to  pass  off 
uncomplicated,  should  the  careful  operator  conclude  to  perform  extrac- 
tion without  iridectomy.  Hence,  it  often  happens  that  it  is  not  decided 
to  do  the  iridectomy  until  after  delivering  the  lens-nucleus  through 
the  round  pupil.  If  it  is  seen  that,  in  spite  of  persistent  attempts 
to  replace  the  iris,  the  pupil  draws  upward  after  each  reposition,  or 
even  if  it  is  suspected  that  the  iris  will  prolapse  later,  iridectomy  is 
indicated.  Because  of  these  precautions  the  reported  percentage  of 
prolapse  of  the  iris  on  the  day  following  the  operation  is  comparatively 
small.  It  occurred  in  8  per  cent,  of  my  patients,  of  which  about  one- 
third  were  operated  without  iridectomy,  and  it  must  be  understood  that 
among  this  8  per  cent,  there  are  included  all  those  cases  in  which  the 
pupil  was  not  absolutely  round,  but  only  slightly  oval-shaped,  without 
a  real  prolapse  in  the  wound. 

The  opening  of  the  capsule  may  be  difficult  in  patients  with  narrow 
pupils,  and  in  such  cases  it  is  advisable  to  use  the  small  tenaculum 
instead  of  the  forceps.  A  narrow  pupil  is  often  a  marked  impediment 
in  the  delivery  of  the  lens,  especially  if  the  nucleus  is  large.  The  opera- 
tor must  decide  whether  or  not  the  lens  can  be  delivered  through  the 
pupil  without  the  use  of  too  strong  pressure,  and  if  not,  perform  an 
iridectomy  rather  than  risk  a  prolapse  of  the  vitreous  by  exerting 
excessive  force. 

The  assistant  can  facilitate  the  removal  of  the  lens  when  the  iris 
is  stretched  ovsr  the  protruding  nucleus  by  attempting  to  push  it  over 
its  edge  at  its  pupillary  margin  with  the  spatula.  The  resistance  of 
the  sphincter,  which  is  particularly  rigid  in  the  iris  of  old  persons,  is 
sometimes  considerable.  The  sphincter  is  occasionally  torn  when  the 


EXTRACTION  OF  SENILE  CATARACT.  1 57 

lens  pushes  through,  and  it  is  then  better  to  perform  an  iridectomy, 
since  the  relaxed  and  lacerated  pupil  fails  to  retain  its  normal  position 
and  becomes  irregular  through  retraction  of  the  margin  of  the  tear. 
If  a  prolapse  of  the  vitreous  occurs  during  the  operation,  an  iridectomy 
is  then  usually  impossible,  and  the  lens  should  be  delivered  with  the 
loop  or  the  double  tenaculum,  in  the  manner  already  described.  The 
iris  in  the  region  of  the  incision  is  turned  backward  and  it  is  only 
\vhen  the  vitreous  floats  it  into  the  wound,  that  the  surgeon  is  in  a  posi- 
tion to  excise  a  portion  which  should  be  as  large  as  possible. 

The  removal  of  the  cortical  substance  is  more  difficult  in  the 
simple  than  in  the  combined  extraction.  If  during  the  expression  of 
the  nucleus,  the  pupil  has  been  pulled  upward  and  the  iris  presents  in 
the  wound,  it  is  advisable  to  massage  the  soft  remaining  particles  of 
the  cortex  out  of  the  eye,  as  in  this  way  only  can  success  attend  subse- 
quent efforts  to  replace  the  iris.  Once  the  pupil  has  regained  its  round 
contour,  massage  carries  the  lens-particles  upward  behind  the  iris, 
without  bringing  them  out  of  the  eye.  Individual  flakes  contained 
within  the  pupillary  space  can  be  removed  with  the  Daviel  spoon. 

The  incision  for  simple  extraction  does  not  differ  from  that  of 
the  ordinary  combined  operation,  but,  here  in  particular,  it  should  be 
the  endeavor  to  make  it  exactly  at  the  limbus. 

After  the  operation  it  is  customary  to  instill  eserin  into  the  eye, 
without,  however,  considering  it  of  any  great  value.  If,  on  the  day 
following  the  operation,  the  pupil  is  not  perfectly  round,  the  wound 
is  re-opened  after  thorough  cocainization,  and  the  iris  resected;  this  is 
done  even  if  the  iris  does  not  lie  directly  in  the  wound.  In  case  of  true 
iris-prolapse,  iridectomy  is  a  foregone  conclusion.  If  the  anterior 
chamber  is  re-established  on  the  second  day  and  the  pupil  round,  the 
further  use  of  eserin  is  quite  unnecessary.  If  the  eye  is  irritated,  atropin 
may  be  employed  as  early  as  the  second  day. 

Excision  of  the  prolapsed  iris  is  usually  difficult,  as  the  irritated 
eye  cannot  be  made  sufficiently  insensitive  by  the  cocain.  The  con- 
sequent wincing  of  the  patient  renders  very  likely  prolapse  of  the  vitre- 
ous. If  the  wound  has  re-opened  with  a  conical  probe,  the  operator 
should  drop  cocain  directly  on  the  exposed  iris.  After  excising  a 
piece  of  the  iris,  it  is  often  an  easy  matter  to  stroke  lens  remnants  out 
of  the  eye,  which  on  the  previous  day  could  not  be  removed.  Replace- 
ment of  such  prolapsed  iris,  without  excising  a  portion,  should  not  be 
considered,  as  in  all  probability  the  prolapse  would  recur. 


CHAPTER  XIII. 
DISCISSION,  OPTICAL  IRIDECTOMY. 

DISCISSION. 

Under  this  heading  are  included  i,  the  incision  of  the  anterior 
lens-capsule  (the  lens  being  either  cloudy  or  transparent),  and  2, 
the  cutting  of  the  secondary  cataracts.  For  the  performance  of  this 


FIG.  88. — Discission  through  the  cornea.  Diagram  showing  how  the  vertical  incision 
is  made  in  discission  through  the  capsule  of  the  lens.  The  handle  of  the  needle  is  lowered, 
thus  bringing  its  point  into  such  a  position  (a)  that  it  lies  near  the  upper  margin  of  the  pupil. 
Next,  while  the  needle  inclines  to  the  plane  of  the  lens-capsule  at  an  angle  of  about  45 
degrees,  the  handle  is  elevated  from  (a)  to  (b),  thus  making  a  vertical  incision  through  the 
capsule. 

operation  discission-needles  are  employed,  which  are  small  knives 
with  convex  and  concave  cutting  edges.  The  incision  may  be  made 
either  through  the  cornea  or  the  sclera,  and  each  operative  procedure 
will  be  considered  separately. 

Discission  through  the  Cornea  (Figs.  88  and  89). — After  the 
pupil  has  been  dilated  with  atropin,  the  eyeball  is  fixed  and  the 

158 


DISCISSIOX,  OPTICAL  IRIDECTOMY.  159 

cornea  pierced  on  the  outer  side  near  the  limbus.  The  operation 
on  the  right  eye  is  best  performed  with  the  left  hand,  and  on  the  left 
eye  with  the  right  hand,  the  operator  in  each  instance  sitting  to  the 
right  of  the  patient.  The  dilatation  of  the  pupil  is  intended  not 
only  to  expose  the  anterior  lens-capsule  as  much  as  possible,  but 
particularly  to  protect  the  iris  from  injury. 

The  needle  is  held  between  the  thumb  and   the  first   and   second 


FIG.  89. — The  eye  is  fixed  below  at  the  limbus  by  means  of  forceps.  With  the  discission 
needle  held  in  the  right  hand,  when  the  left  eye  is  operated  on,  the  cornea  is  perforated  at 
the  limbus,  and  a  horizontal  incision  is  then  performed  through  the  anterior  lens-capsule. 


fingers,  while  its  handle  rests  upon  the  base  phalanx  of  the  fore- 
finger. After  perforating  the  cornea  in  about  the  horizontal  merid- 
ian, the  knife-point  is  pushed  forward  and  upward,  until  it  reaches 
the  upper  margin  of  the  pupil.  Using  the  corneal  perforation  as  the 
rotating  point,  the  handle  of  the  instrument  is  moved  from  below 
upward,  describing  an  arc  of  about  90  degrees,  and  held  so,  that  its 


l6o  OPHTHALMIC    SURGERY. 

long  axis  is  inclined  to  the  plane  of  the  lens-capsule  at  about  an  angle 
of  45  degrees.  In  this  way  the  point  of  the  knife-needle  makes  an 
incision  into  the  capsule  from  above  downward,  cutting  through 
the  lens-substance  obliquely  (Fig.  88).  After  completing  the  verti- 
cal capsular  opening,  the  point  of  the  instrument  is  brought  back 
in  the  anterior  chamber  by  depressing  the  handle,  and  approached  to 
the  inner  margin  of  the  pupil.  Starting  from  an  almost  horizontal 
position  of  the  needle,  the  handle  of  the  instrument  is  elevated  now 
through  an  arc  of  about  45  degrees,  the  corneal  perforation  being 
utilized  again  as  a  fulcrum.  Through  this  maneuver  the  point  of 
the  needle  describes  a  small  arc  and  makes  a  horizontal  incision 
in  the  anterior  capsule  of  the  lens  (Fig.  89).  In  order  that  the  point 
does  not  sink  too  deeply  and  injure  the  posterior  capsule,  the  needle 
is  withdrawn  slightly  while  making  the  cut  and  finally  quickly  pulled 
out  of  the  eye. 

The  most  important  precaution  in  the  operation  is  to  avoid  injuring 
the  posterior  capsule  of  the  lens.  This  accident  may  result  from 
introducing  the  needle  too  deeply,  and  directing  it  too  perpendicularly. 
On  that  account  the  needle  should  be  made  to  glide  obliquely  through 
the  substance  of  the  lens  during  the  vertical  incision,  and  be  drawn  out 
of  the  eye  during  the  horizontal  incision.  If  the  instrument  is  inserted 
too  perpendicularly,  a  perforation  of  the  posterior  lens-capsule  readily 
occurs. 

The  opening  in  the  anterior  chamber  may  be  made  either  in  the 
outer  part  of  the  cornea  or  in  the  limbus  itself  or  even  beyond  it  in  the 
sclera.  In  entering  through  the  sclera  the  needle  is  pushed  forward 
slightly  under  the  bulbar  conjunctiva  before  the  perforation  is  com- 
pleted. This  produces  immediate  closure  of  the  perforation-wound, 
as  the  opening  in  the  conjunctiva  and  that  in  the  eyeball  occupy 
different  positions.  However,  entering  the  knife  through  the  cornea 
is  preferable  in  those  cases  in  which,  because  of  a  shallow  anterior 
chamber  or  a  pupil  which  has  remained  small  in  spite  of  atropin,  an 
injury  to  the  iris  is  to  be  feared  if  a  peripheral  incision  is  made. 

As  for  opening  in  the  capsule  we  prefer  a  crucial  incision,  because 
a  permanent  opening  is  thereby  assured.  The  four  flaps  retract,  so 
that  a  healing  of  the  wound  in  the  capsule  is  absolutely  prevented.  If 
only  a  single  incision  is  made,  closure  of  the  wound  not  infrequently 
occurs.  On  the  other  hand  more  than  two  incisions  are  superfluous. 

The  aqueous  humor  should  not  be  allowed  to  escape  during 


DISCISSIOX,  OPTICAL  IRIDECTOMY.  l6l 

the  operation.  On  this  account,  the  needle  must  be  quickly  with- 
drawn from  the  eye.  Through  the  escape  of  the  aqueous  humor, 
adhesion  of  the  iris  to  the  place  of  perforation  may  develop,  thus  leading 
to  the  formation  of  an  anterior  synechia. 

Discission  of  a  transparent  lens  is  only  undertaken  in  high-grade 
myopia,  for  the  purpose  of  completely  removing  the  lens.  The  imme- 
diate consequence  of  discission  is,  of  course,  a  traumatic  cataract. 
The  rapidity  with  which  this  forms  depends  chiefly  upon  the  size  of  the 
capsular  wound.  If  only  a  single  cut  has  been  made,  the  opacity 
not  infrequently  remains  limited  to  the  tissue  immediately  surrounding 
it  as  the  capsular  wound  may  close  in  the  meantime.  Therefore,  if 
after  a  few  days,  the  cataract  should  make  no  progress,  it  is  best  to 
repeat  the  discission,  and  to  incise  the  capsule  of  the  lens  more 
freely.  If  the  anterior  lens-capsule  is  opened  sufficiently,  there  is 
not  only  a  total  opacity  of  the  lens  quickly  produced,  but  also  a  swelling 
of  the  lenticular  substance  which  soon  fills  the  anterior  chamber. 

The  swollen  lens-substance  is  rather  slow  in  being  absorbed  and  many 
weeks  may  be  required,  during  which  the  eye  is  in  a  state  of  constant 
irritation.  Hence,  we  prefer  after  about  fourteen  days,  by  which 
time  the  entire  lens  has  become  opaque  and  soft,  to  remove  the  masses 
from  the  eye  by  an  incision  made  with  the  lancet  at  the  lower  corneal 
margin  (analogous  to  linear  extraction).  Provided  the  posterior  lens- 
capsule  has  not  been  injured  by  the  discission,  this  trifling  operation 
is  performed  without  accident,  especially  as  an  incision  5  mm.  long 
usually  suffices.  If,  however,  the  posterior  lens-capsule  has  been 
injured  in  performing  the  discission,  prolapse  of  the  vitreous  body 
into  the  wound  is  the  immediate  consequence.  This,  of  course,  makes 
impossible  the  massaging  of  the  soft  lenticular  masses  from  the  eye, 
as  more  vitreous  would  be  squeezed  out.  The  iris  is  likewise  dis- 
placed from  its  proper  position  by  the  vitreous  and  remains  perma- 
nently distorted.  For  the  foregoing  reasons  the  operator  should  be 
particular  not  to  injure  the  posterior  lens-capsule. 

During  the  period  of  swelling  of  the  lens,  the  pupil  must  be  kept 
widely  dilated  by  atropin.  The  development  of  the  cataract  is  suffi- 
cient in  itself  to  setup  a  state  of  intense  irritation  and  ciliary  hyperemia; 
and  atropin  is  necessary,  not  only  to  hinder  the  formation  of  posterior 
synechia,  but  to  freely  and  constantly  expose  the  capsular  wound  and 
prevent  incarceration  of  the  swelling  lens-substance  in  the  narrowing 
pupil,  which  would  soon  terminate  in  increase  of  pressure.  The 


1 62  OPHTHALMIC    SURGERY. 

latter,  moreover,  not  infrequently  follows  the  swelling  of  the  lens  after 
discission,  and  especially  when  the  incisions  are  free  so  that  the  swelling 
takes  place  rapidly.  If  the  tension  increases  and  the  pupil  is  not 
dilated  sufficiently,  it  should  be  our  first  task  to  open  the  pupil  as 
much  as  possible  by  thorough  cocainization  followed  by  the  application 
of  dry  atropin,  and  at  the  same  time  apply  iced  compresses  to  the  closed 
lids  which  exercise  a  beneficial  influence.  If  the  pupil  is  sufficiently 
dilated,  we  must  not  instill  miotics  with  the  hope  of  decreasing  pressure. 
If  the  glaucoma  does  not  disappear  within  24  hours  and  at  the  same 
time  is  considerable,  a  puncture  of  the  anterior  chamber  will  remove 
it  permanently,  by  which  we  try  to  get  out  as  much  of  the  swollen  lens 
as  possible,  as  previously  described. 

The  indications  for  the  operation  in  high-grade  myopia  are 
as  follows: 

1.  The  degree  of  myopia  must  be  more  than  16  diopters;  if  patients 
with  less  myopia  are  operated  on,  they  will   require  after  operation 
convex  glasses  for  distance  vision  and  still  stronger  lenses  for  near 
vision.     The  difference  in  the  refraction  produced  by  the  removal 
of  the  lens  in  myopia  amounts  to  nearly  20  diopters  on  an  average,  as 
against  10  diopters  in  normal  eyes. 

2.  The  visual  acuity  of  the  eye  to  be  operated  upon  must  not  have 
suffered  too  severely  through  intraocular  changes  and  must  at  least 
be  one-sixth  to  one-quarter  of  the  normal  and  not  seriously  disturbed 
by  a  central  scotoma. 

3.  The  patient's  othef  eye  must  still  be  useful,  that  is,  it  must  not 
have  suffered  detachment  of  the  retina,  severe  chorioiditic  processes, 
or  other  diseases. 

4.  The  operation  is  limited  to  patients  under  forty  years  of  age. 
Narrowing  the  foregoing  indications  down  to  these  limits,  the  results 

obtained  by  the  operation  are  on  an  average  good.  It  is  of  the  greatest 
importance  to  guard  against  injuring  the  vitreous  during  the 
operative  procedures.  It  must  be  remembered  that  in  high  myopia 
the  vitreous  shows  a  marked  tendency  to  become  diseased.  But  it 
becomes  frequently  impossible  to  leave  this  humor  permanently  undis- 
turbed. While  it  is  the  duty  of  the  operator  not  to  injure  the  vitreous 
in  performing  discission  of  the  transparent  lens,  it  often  happens  that, 
after  the  removal  of  the  lens,  a  secondary  cataract  develops  through 
subsequent  thickening  of  the  capsule  of  the  lens,  which  makes  further 
operations  necessary.  Naturally  this  cannot  be  done  without  injury 


DISCISSION,  OPTICAL  IRIDECTOMY.  163 

to  the  vitreous.  There  is  no  doubt  that  eyes  operated  upon  for 
myopia  are  especially  prone  to  develop  detachment  of  the  retina,  and 
the  patient's  attention  should  be  called  to  all  the  possibilities  of  disaster 
before  the  operation,  and  especially  should  it  be  stated  that  the  oper- 
ation is  no  guarantee  against  the  serious  intraocular  changes  that 
usually  occur  sooner  or  later  as  a  consequence  of  the  high  grade  myopia. 

Discission  is  also  used  for  the  removal  of  partial  cataract.  In 
this  latter  variety,  besides  discission  for  removal  of  the  lens,  optical 
iridectomy  must  also  be  considered. 

Discission  for  the  Removal  of  Totally  Opaque  Lenses. — In 
congenital  total  cataract,  discission  is  the  only  safe  operation.  Linear 
extraction  is  recommended  only  in  patients  of  relatively  advanced 
age  and  considerable  intelligence,  so  they  may  be  relied  upon  to  remain 
quiet  during  and  after  the  operation.  On  that  account,  in  children 
we  are  accustomed  to  perform  discission,  as  no  extreme  precautionary 
measures  are  demanded  and  there  is  ample  time  to  wait  until  spon- 
taneous absorption  of  the  lens  has  taken  place.  The  latter  progresses 
usually  promptly  and  completely  in  young  patients.  Occasionally 
it  may  be  necessary  to  perform  discission  a  second  or  even  third  time. 
Not  infrequently  after  discission  of  even  shrunken  cataracts  in  children, 
an  increase  in  intraocular  pressure  develops,  which  usually  dis- 
appears, however,  within  a  few  days  by  the  use  of  eserin  and  cold 
compresses.  Only  in  rare  instances  will  puncture  of  the  cornea  be 
necessary  and  the  incision  should  not  be  longer  than  2  millimeters  at 
the  most,  so  that  danger  of  prolapse  of  the  iris  may  be  excluded. 

As  already  noted,  in  some  cases  of  congenital  complete  cataract 
in  children,  there  is  a  greatly  shrunken  lens,  so  that  in  the  course  of 
discission  after  dividing  the  membrane,  which  consists  of  the  anterior 
and  posterior  capsule  with  remains  of  slightly  clouded  lens,  a  black 
space  immediately  makes  its  appearance. 

In  total  cataract  of  young  adults  the  operation  giving  the  most 
rapid  results  is  linear  extraction.  We  usually  employ  it  in  patients 
over  the  age  of  12,  but  even  in  these  cases  discission  followed  even- 
tually by  puncture  of  the  anterior  chamber  may  be  given  pref- 
erence. As  the  cataract  in  such  eyes  is  often  a  complicated  one,  it 
may  happen  that  the  fluid  vitreous  escapes  from  the  wound  as  soon 
as  the  incision  has  been  made  with  the  lancet.  In  this  event  a  supple- 
mentary discission  of  the  capsule  of  the  lens  must  suffice,  as  it  would 
be  impossible  to  remove  by  massage  the  lens-masses  from  the  eye. 


164  OPHTHALMIC    SURGERY. 

OPTICAL  IRIDECTOMY. 

The   indications   for   optical   iridectomy  are   as   follows:     In 

soft  lenses,  with  perinuclear  opacities  which  only  slightly  interfere  with 
visual  acuity,  it  is  best  not  to  operate  at  all.  In  all  other  cases  the 
tests  should  be  made  with  the  ordinary  size  of  the  pupil  and  afterward 
with  fully  dilated  pupil.  If  the  vision  is  improved  by  the  dilatation 
of  the  pupil — in  cases  in  which  the  diameter  of  the  central  disc-shaped 
cataract  is  a  small  one — and  is  brought  to  a  degree  suitable  for  the 
necessities  of  the  individual  concerned,  i.e.,  at  least  a  third  of  the 
normal  acuity,  this  degree  of  sight  can  be  obtained  permanently  by  an 
optical  iridectomy,  whereby  the  patient  has  the  advantage  of  still 
possessing  the  lens  and  with  it  the  power  of  accomodation.  In  such 
case,  the  coloboma  is  best  made  below  and  to  the  inner  side. 

If,  however,  the  improvement  in  vision  following  dilatation  of  the 
pupil  is  not  sufficient,  discission  of  the  cataract  is  indicated.  By 
this  means  the  opacity  can  be  completely  removed,  and  the  visual 
power  returned  to  its  normal  range.  The  patient,  of  course,  is  forced 
to  wear  permanently  strong  convex  glasses.  In  the  greater  number 
of  cases  of  perinuclear  cataract  the  latter  operation  is  indicated,  and 
in  a  much  smaller  number,  iridectomy.  The  objection  made  against 
iridectomy  that  the  cataract  will  probably  become  progressive  and 
lead  to  total  opacity  of  the  lens,  thus  rendering  the  operation  value- 
less, is,  however,  not  sustained. 

The  technic  of  optical  iridectomy  differs  from  that  of  iridec- 
tomy for  glaucoma  not  only  in  the  method  of  incision  but  also  in  the 
type  of  excision  of  the  iris.  As  the  purpose  of  optical  iridectomy 
is  to  alter  the  position  of  the  pupil  slightly,  only  that  portion  of  the 
iris  which  borders  on  the  pupillary  margin  should  be  excised.  As  the 
periphery  of  the  iris  must  be  preserved  for  optical  reasons,  the  incision 
is  placed  in  the  limbus  or  a  little  to  its  inner  side  in  the  cornea.  Other- 
wise, essentially  the  same  details  are  followed  as  in  iridectomy  for 
glaucoma.  The  incision  is  made  with  the  lancet,  except  in  cases  in 
which  a  shallow  anterior  chamber,  for  example,  one  the  result  of  an 
anterior  synechia,  makes  the  use  of  the  Graefe  knife  necessary.  When- 
ever possible,  the  coloboma  is  placed  to  the  inner  and  lower  side,  as 
experience  shows  that  this  position  gives  the  best  optical  results. 
Very  often,  however,  another  portion  of  the  cornea  must  be  selected, 
as  the  remainder  of  the  corneal  surface  has  lost  its  transparency 
because  of  extensive  opacities.  Of  course,  it  is  readily  understood 


DISCISSIOX,  OPTICAL  IRIDECTOMY.  165 

thai  care  must  be  taken  that  the  coloboma  is  not  entirely  covered 
by  the  upper  lid.  If  in  a  one-eyed  individual  only  the  part  of  the 
cornea  covered  by  the  upper  lid  remains  transparent  and  is  suitable 
for  an  optical  iridectomy,  nothing  remains  but  to  produce  a  per- 
manent depression  of  the  eyeball  by  tenotomizing  the  superior  rectus, 
so  that  the  coloboma  will  lie  uncovered  in  the  palpebral  fissure. 

The  iris  is  withdrawn  with  the  forceps  in  the  same  manner  as  pre- 
viously described.  It  is  sufficient,  however,  to  draw  out  the  smallest 
possible  fold  and  to  cut  off  the  tip  with  the  blades  of  the  de  Wecker's 
scissors  held  perpendicular  to  the  corneal  incision.  In  this  manner, 
a  coloboma  limited  to  the  central  part  of  the  iris  is  produced,  which  at 
once  enlarges  considerably  by  retraction  of  its  margins. 

Precorneal  iridotomy  is  an  operation  to  obtain  a  smaller  coloboma. 
In  this  operation,  after  the  lancet-incision  has  been  made,  the  iris  is 
seized  at  its  pupillary  margin  and  drawn  out  of  the  wound.  A 
small  radial  incision  is  made  in  the  pupillary  margin,  after  which 
the  iris  is  replaced.  As  both  ends  of  the  sphincter  retract,  the  cut 
turns  into  a  coloboma  of  such  a  size  that  it  is  nearly  impossible  to 
recognize  whe  her  it  has  been  produced  by  an  iridotomy  or  an  iridec- 
tomy. As,  however,  this  precorneal  operative  method  has  undoubted 
disadvantages,  the  most  important  of  w-hich  is  the  surgical  un- 
cleanness  of  the  procedure,  namely,  replacing  the  iris  lying  in  the 
conjunctival  sac  into  the  eye,  the  regular  iridectomy  is  decidedly 
preferable. 

The  ideal  indication  for  an  optical  iridectomy  is  when  corneal 
scars  cover  the  center  of  the  pupillary  area.  In  order  that  we  should 
not  be  disappointed  by  the  actual  results  of  an  optical  iridectomy, 
a  careful  examination  of  the  cornea  with  the  magnifying  lens,  to 
ascertain  the  condition  of  the  so-called  transparent  parts  of  the  cornea, 
is  particularly  demanded.  Delicate  diffuse  opacities  will  frequently 
be  found  in  those  portions  which  were  judged  to  be  of  perfectly  normal 
transparency  when  examined  with  the  naked  eye.  Not  until  the 
iridectomy  is  completed,  are  the  corneal  opacities  easily  visible  against 
the  black  background,  and  they  then  often  seem  quite  intense,  while 
previously  they  entirely  escaped  the  notice  of  the  less  careful  observer. 
In  making  an  examination  with  the  magnifying  lens,  not  only  those 
portions  of  the  cornea  must  be  looked  for  which  are  at  the  same 
time  the  most  central  and  transparent,  but  also  we-  must  take  into 
consideration  the  areas  where  the  opacity  contrasts  most  sharply  with 


1 66  OPHTHALMIC    SURGERY. 

the  surrounding  parts.  The  sharper  the  margin,  the  denser  the 
opacity;  the  broader  the  remaining  transparent  border,  the  better  the 
outlook  for  a  good  result. 

Recourse  to  an  optical  iridectomy  should  not  be  had  too  early  in 
cases  of  corneal  opacity.  Opacities  resulting  from  deep-seated  kerat- 
itis,  especially  after  parenchymatous  keratitis  in  young  people,  often 
clear  up  slowly  after  many  months.  On  the  other  hand,  not  much 
clearing  up  of  scars  after  severe  ulcerative  processes  in  adults,  should 
be  expected.  The  cases  particularly  suitable  for  an  optical  iridectomy 
are  those  in  which  the  opacity  has  resulted  from  a  \vell-circumscribed 
area  of  disease  (especially  from  ulcus  serpens,  infected  wounds,  etc.) 
while  the  rest  of  the  cornea  has  remained  approximately  well.  Con- 
ditions for  a  good  result  are  much  less  favorable  when  the  opacities 
have  resulted  from  deep  corneal  inflammations,  because  the  cornea  is 
usually  so  affected  that  delicate,  grayish,  indefinite  areas  are  found 
throughout  its  entire  surface.  The  optical  iridectomy,  therefore, 
improves  the  vision  but  little,  even  when  the  pupillary  area  of  the 
cornea  is  affected  by  a  rather  dense  opacity.  It  must  be  remembered 
that  the  diffuse  haziness  of  the  peripheral  portion  of  the  cornea  often 
causes  marked  disturbance  of  vision. 

In  any  event,  an  exact  determination  of  the  visual  acuity  after 
painstaking  correction  of  the  errors  of  refraction  (especially  astig- 
matism) by  the  use  of  the  stenopaeic  disk  is  necessary.  For  this  pur- 
pose, Fritsch,  of  Vienna,  has  constructed  a  movable  stenopaeic  disk, 
which  may  not  only  be  placed  into  the  various  meridians  by  merely 
turning  it,  but  can  be  easily  shifted  into  a  horizontal  and  vertical 
position.  At  the  same  time  it  is  lodged  in  such  a  frame  that  it  can 
readily  be  adjusted  to  any  pair  of  spectacles.  As  often  only  a  certain 
definite  position  of  the  slit  gives  the  patient  a  substantial  improve- 
ment in  vision,  the  ordinary  examination,  with  the  trial  frame  com- 
monly found  in  the  test-case,  does  not  serve  the  purpose.  The  tests 
with  the  disk  should  be  carried  out  by  adjusting  it  to  the  glasses  which 
the  patient  is  constantly  wearing.  For  this  purpose,  we  determine 
first  as  well  as  possible  on  the  naked  eye  of  the  patient,  the  lens  that 
gives  him  relatively  the  best  vision  for  near  work  and  for  distance. 
Not  until  the  patient  has  received  the  prescribed  lenses  from  the 
optician,  is  the  position  of  the  stenopaeic  slit  determined  by  attaching 
the  instrument  to  them.  The  position  in  which  the  optician  has  to 
place  the  stenopeic  slit  on  the  glasses,  is  then  readily  decided.  This 


DISCISSION,  OPTICAL  IRIDECTO.MY.  167 

accurate  procedure  is  of  the  greatest  importance,  especially  for  those 
patients  who  are  dependent  upon  one  eye.  The  improvements 
occasionally  produced  by  application  of  the  stenopaeic  disk  are  quite 
marked,  and  not  infrequently  the  vision  can  be  increased  from  finger- 
counting  at  2  meters  to  6/24  or  6/18,  thus  making  possible  reading 
and  writing. 

As  already  stated  optical  iridectomy  is  usually  performed  in  cases 
with  dense  central  corneal  opacities  rather  sharply  defined  from 
surrounding  healthy  cornea.  Before  deciding  on  the  operation  we 
must  first  determine  provisionally  the  effect  of  an  optical  iridectomy 
by  dilating  the  pupil  with  atropin.  Artificial  mydriasis,  however, 
cannot  be  exactly  compared  to  that  produced  by  an  optical  iridectomy, 
as  atropin  dilates  the  pupil  symmetrically;  but  the  operator  learns 
from  such  an  examination  that  in  complete  absence  of  improvement 
from  uncovering  a  portion  of  the  pupil  behind  a  less  clouded  part  of 
the  cornea,  a  satisfactory  result  cannot  be  expected  from  an  optical 
iridectomy.  Moreover,  if  the  patient's  vision  is  lessened  by  dilatation 
of  the  pupil,  a  permanent  reduction  in  his  sight  will  follow  by  per- 
forming an  optical  iridectomy,  as  it  is  just  in  such  cases  that  the  impair- 
ment of  the  sight  is  dependent  upon  the  irregular  diffusion  of  the 
rays  of  light.  It  happens  not  infrequently  that  persons  with  diffuse 
corneal  opacities  see  much  better  with  a  contracted  pupil  (comparable 
to  a  stenopaeic  disk),  than  with  the  pupillary  orifice  widened. 

Frequently,  also,  it  is  necessary  to  decide  whether  it  is  not  possible 
to  improve  the  vision  by  tattooing  of  the  cornea,  with  or  without 
subsequent  iridectomy.  In  such  cases  it  is  recommended  to  tattoo 
the  corneal  scars  provisionally  as  it  were,  by  applying  a  piece  of  fine 
silk  paper,  absolutely  black  in  color  and  cut  as  to  exactly  fit  the  opacity 
in  the  cornea.  This  paper  adheres  readily  and  makes  possible  a  test 
of  the  visual  power  for  comparison  with  the  earlier  test.  In  order  that 
the  piece  of  paper  can  be  applied,  the  cornea  should  be  rendered 
anesthetic  by  the  use  of  alypin,  which  unlike  cocain  has  no  influence 
on  the  pupil,  so  that  there  is  no  artificial  dilatation  to  interfere  with  the 
examination. 

On  the  whole  the  results  of  optical  iridectomy  in  corneal  opacity 
are  only  mcderate,  and  the  cases  suitable  for  the  performance  of  this 
operation  are  relatively  few.  The  bcncficient  clearing  effect  on 
corneal  opacities  which  has  been  ascribed  to  iridectomy  depends  prob- 
ably only  upon  a  delusion,  occasioned  in  eyes  in  which  surgical  inter- 


1 68  OPHTHALMIC    SURGERY. 

ference  was  undertaken  too  early.  Optical  iridectomy  gives  much 
more  favorable  results  in  central  lenticular  opacity,  that  is,  large 
central  capsular  cataract  and  especially  in  large  lamellar  cataract 
in  which  the  opacity  is  sharply  defined  and  has  a  small  diameter. 

Exudates,  such  as  the  connective-tissue  membranes  in  the  pupillary 
area  following  iritis,  also  afford  an  indication  for  optical  iridectomy. 
Of  course,  due  consideration  must  be  given  to  the  usually  existing 
adhesions  of  the  iris  to  the  capsule  of  the  lens  resulting  from  the  iritis, 
and  a  broader  iridectomy  performed  in  order  to  prevent  a  later  rise 
in  pressure.  It  must  also  be  remembered  that  the  result  can  be 
nullified  by  the  pigmented  layer  of  the  iris-membrane  adhering  to  the 
capsule  of  the  lens  and  covering  the  coloboma. 


CHAPTER  XIV. 

SECONDARY    CATARACT.     IRIDOTOMY.     LINEAR 
EXTRACTION. 

DISCISSION  IN  SECONDARY  CATARACT. 

As  a  secondary  cataract  forms  the  only  septum  between  the  aqueous 
and  the  vitreous  chambers,  discission  cannot  be  performed  without 
some  injury  to  the  vitreous,  which  always  should  be  as  little  as  possible. 
In  other  details  the  operation  is  done  in  the  same  manner  as  already 
described,  and  here  also  the  pupil  must  first  be  widely  dilated  by 
atropin;  a  good  side  illumination  from  the  lamp  is  important,  especially 
in  those  cases  with  a  glassy  membrane  in  which  the  pupil  occasionally 
appears  quite  black.  If  after  the  first  incision  a  free  space  is  noted  at 
once,  the  needle  must  be  withdrawn.  Only  when  the  first  cut  is  with- 
out result  is  a  second  or  third  made  in  different  directions,  never 
penetrating  the  vitreous  body  deeply. 

Complications. — If  the  pupil  is  held  by  posterior  synechia,  so  that 
dilatation  by  atropin  is  impossible,  the  operation  becomes  somewhat 
more  difficult,  although  an  injury  to  the  iris  can  be  averted  in  conse- 
quence of  the  great  depth  of  the  anterior  chamber. 

If  the  membrane  is  tough,  and  has  become  adherent  to  the  margin 
of  the  pupil,  it  may  evade  the  needle  and  be  pushed  back  under  marked 
pulling  of  the  iris,  even  producing  laceration  into  the  attachment  of 
the  iris  (iridodialysis) ;  or  it  gives  way  to  the  knife  by  detaching  itself 
from  the  iris  at  one  point  and  becomes  pressed  backward  like  a  lid, 
returning  quickly  to  its  original  position  in  the  pupil  when  the  needle 
is  drawn  forward,  so  that  the  result  of  the  operation  is  frustrated. 

If  we  fail  to  incise  the  membrane,  it  is  useless  to  repeat  the  foregoing 
maneuvers,  but  resort  should  be  had  to  a  discission  with  two  needles 
(Bowman).  In  this  procedure  one  needle  is  introduced  from  the 
outer  and  the  other  from  the  inner  side  of  the  cornea,  the  needles 
crossing  so  that  the  point  of  the  former  lies  near  the  inner  margin  of 
the  pupil,  and  that  of  the  latter  near  the  outer  margin.  By  raising 
the  handles,  the  needles  are  moved  in  opposite  directions  and  accom- 
plish a  tearing  asunder  (dilaceration)  of  the  membrane.  Combined 

169 


170 


OPHTHALMIC    SURGERY. 


discission  with  one  needle  entered  through  the  cornea  and  the  other 
through  the  sclera  may  also  be  of  advantage. 

The  operation  with  the  needle  is  suited  for  cases  in  which  the  second- 
ary cataract  consists  only  of  the  capsule  and  the  remnants  of  the  lens. 
But  if  the  membrane  contains  a  layer  of  connective-tissue,  following 
an  iridocyclitis  after  a  cataract-extraction,  the  needle  is  not  sufficiently 
strong  to  freely  divide  it.  In  such  cases  it  must  be  replaced  by  the 
v.  Graefe's  knife  and  the  operation  is  then  called  capsulotomy,  or, 
if  at  the  same  time  some  iris  must  be  cut  into,  iridotomy. 


FIG.  90. — Iridotomy.  The  pupil  is  displaced  upward  by  the  scar  resulting  from  the 
cataract  operation,  and  is  obstructed  by  a  membrane.  The  patient  is  looking  well  upward ; 
the  eye  is  fixed  at  the  side.  The  von  Graefe  knife,  directed  obliquely  upward,  is  introduced 
into  the  cornea  in  the  vertical  meridian  rather  close  to  the  lower  limbus;  the  edge  of  the 
knife  is  directed  backward. 

The  application  of  iridotomy  may  best  be  illustrated  by  a  typical 
case.  If,  after  an  extraction  with  loss  of  vitreous,  the  pupil  is  drawn 
upward  into  the  region  of  the  dense  scar  and  closed  by  a  membrane 
consequent  upon  an  iritis,  the  accompanying  picture  (Fig.  90)  may 
be  seen.  Before  any  operative  procedures  are  undertaken,  it  is 
necessary  to  make  sure  of  gocd  light-perception  and  projection, 
and  also  to  wait  until  the  inflammation  of  the  eye  has  completely 
subsided  and  the  irritation  of  the  eyeball,  manifested  by  the 
appearance  of  mild  ciliary  injection,  is  no  longer  occasioned.  The 


SECONDARY    CATARACT.       IRIDOTOMY.  171 

contemplated  operation  must  accomplish  two  purposes,  namely,  to  clear 
the  pupil  and  to  alter  its  position,  so  that  it  will  come  to  lie  behind  the 
center  of  the  cornea.     It  is  not  sufficient,  therefore,  to  simply  cut  the 
membrane  in  the  pupil,  but  the  incision  must  extend  through  the  iris 
and   the   dense   fibrous   membrane   which   lies  behind   it.     For   this 
purpose  the  cornea  is  penetrated  below  by  a  sharp  Graefe's  knife,  the 
cutting  edge  of  which  is  backward  while  the  point  is  directed  upward 
toward  the  pupil     A  vertical  incision   (Fig.  91).  from  above  down- 
ward is  made  through  the  pupillary  membrane  and  the 
iris,  producing  a    vertical  fissure   which   extends    to        . 
below  the  center  of  the  cornea.     Only  a  very  sharp 
knife  will  divide  the  membrane  without  pulling  on 
the  iris.     Iridc dialysis  may  occur  if  the  membrane     ^n  mdotom y!°' 
together  with  the  attached  iris  evades  the  knife  and  is 
pressed  backward.     It  is  frequently  observed  that  the  dense  membrane 
is   readily  divided,  while  the  delicate  tissue  of  the  iris  escapes  the 
knife,   resisting  all  attempts  to  incise  it. 

After  the  incision  has  been  completed,  the  knife  is  withdrawn  and 
pressure  immediately  exerted  on  the  eye  through  the  closed  lids  by 
means  of  the  finger,  and  a  pressure-dressing  applied  at  once.  A 
firm  bandage  is  of  the  greatest  importance  in  preventing  hemor- 
rhage, which  can  occur  not  only  from  the  cut  vessels  of  the  iris,  if  the 
latter  has  been  incised,  but  also  from  division  of  the  newly  formed 
vessels  found  in  the  dense  fibrous  secondary  membrane.  Such  hemor- 
rhage would  make  the  entire  result  of  the  operation  doubtful  and  in 
most  cases  render  it  worthless.  From  extensive  experience  we  know 
how  difficult  of  absorption  is  a  hemorrhage  in  the  anterior  chamber 
in  eyes  affected  by  a  chronic  iridocyclitis.  If  after  many  weeks  the 
blood  gradually  disappears,  it  will  usually  be  found  that  the  clear 
space  obtained  by  the  operation  is  again  closed  by  a  fibrous  membrane 
formed  by  organization  of  the  clot.  We  are  accustomed  to  remove 
the  pressure  bandage  after  six  to  eight  hours,  and  to  replace  it  by  an 
ordinary  protective  dressing.  By  this  time  a  sufficient  closure  of  the 
injured  vessels  has  taken  place,  and  a  secondary  hemorrhage  need  not  be 
feared.  The  many  published  bad  results  of  the  iridotomy  just  de- 
scribed, can  usually  be  traced  to  neglect  of  the  proper  procedures  for 
the  prevention  of  hemorrhage. 

The  depth  of  the  anterior  chamber  is  not  decreased  by  iridotomy, 
and  a  prolapse  of  the  vitreous  is  impossible.  The  dressing  may  be 


172  OPHTHALMIC    SURGERY. 

removed  as  early  as  the  day  after  operation,  and  rest  in  bed  is  not 
necessary.  Provided  that  no  serious  intraocular  conditions  exist 
(dense  vitreous  opacities,  retino-chorioiditic  areas,  etc.),  vision  may 
become  good.  However,  these  complications  are  not  infrequent,  and 
the  unsatisfactory  results  must  not  be  attributed  to  the  operation. 

A  vertical  incision  gives  the  advantage  of  cutting  approximately 
parallel  to  the  fibers  of  the  iris  without  seriously  injuring  any  of  its 
vessels.  The  disadvantage  of  making  the  incision  in  the  direction  of 
the  fibers  of  the  iris  arises  from  the  fact  that  the  cut  shows  no  tendency 
to  gape  and  sometimes  exists  only  as  a  fine  line,  which  soon  closes 
completely  through  the  accurate  application  of  the  wound-edges. 
If  a  horizontal  incision,  running  transversely  to  the  direction  of  the 
iris-fibers,  is  used,  we  are  able  to  make  it  at  any  height  desired  (there- 
fore, exactly  behind  the  center  of  the  cornea),  and  in  addition  produce 
a  broader  gap  through  retraction  of  the  iridal  tissue.  A  horizontal 
incision,  it  is  true,  divides  many  more  of  the  blood-vessels  of  the  iris, 
and,  therefore,  the  pressure-dressing  must  be  applied  to  the  eye  with 
special  rapidity  after  the  incision  has  been  made.  If,  however,  as  is 
not  infrequently  the  case,  the  iris  has  undergone  a  fairly  high  degree 
of  atrophy,  a  large  number  of  the  iridal  vessels  will  have  been  obliter- 
ated and  the  injury  to  them  is  of  but  little  importance. 

Should  the  result  be  unsatisfactory,  there  is  no  objection  to  an 
early  repetition  of  the  operation,  provided  that  the  eye  is  not  much 
irritated. 

The  foregoing  method  of  iridotomy  is  the  only  operation  we  employ 
in  cases  of  complicated  secondary  cataract.  Its  superiority  over  the 
various  other  operations-  recommended  (discission  after  de  Wecker, 
etc.),  consists  in  not  opening  the  anterior  chamber  thus  making  a  loss 
of  vitreous  impossible,  in  its  greater  rapidity,  in  the  careful  handling 
accorded  to  the  iris,  and  in  the  almost  invariable  satisfactory  result,  if 
such  an  issue  of  the  operation  is  at  all  possible. 

Discission  through  the  sclera  (Fig.  92). — This  operation  is  adapted 
only  to  secondary  cataract.  The  needle  should  be  stronger  than  that 
ordinarily  employed  for  discission  through  the  cornea.  By  entering 
through  the  sclera,  there  is  the  advantage  of  being  able  to  use  more 
force  in  dividing  the  membrane  than  is  possible  by  the  operation 
from  the  front. 

To  avoid  various  unpleasant  complications,  the  perforation  with 
the  needle  must  be  made  posterior  to  the  ciliary  body,  that  is,  at  a 


SECONDARY    CATARACT.       IRIDOTOMY. 


173 


distance  of  at  least  6  millimeters  from  the  limbus  and  either  above  or 
below  the  horizontal  meridian,  so  as  not  to  injure  the  posterior  long 
ciliary  artery.  It  is  easier  to  enter  at  the  outer  and  inferior  side, 
while  the  patient  looks  upward  and  inward,  and  the  eye  is  held  in  this 


position  by  forceps.  The  needle  is  directed  forward  and  pushed 
through  the  membrane  in  the  pupil  so  that  the  point  appears  in  the 
anterior  chamber  (Fig.  92).  By  elevating  the  handle  of  the  instrument 
the  membrane  is  divided.  In  order  not  to  injure  the  vitreous  more 


174  OPHTHALMIC    SURGERY. 

than  is  necessary,  as  few  cuts  as  possible  are  made.  If,  after  the  first 
cutting  movement,  a  black  space  is  seen  to  appear  in  the  membrane, 
the  needle  is  quickly  withdrawn  from  the  eye.  Only  in  case  the  first 
incision  fails  to  produce  a  free  opening,  and  simply  depresses  the 
membrane  so  that  it  springs  back  again  into  the  pupil,  must  a  second 
or  third  attempt  be  made  to  incise  it.  The  injury  to  the  vitreous 
incurred  by  this  method  is  no  greater  than  when  the  operation  is 
performed  through  the  cornea.  In  all  cases  of  secondary  cataract, 
injury  to  the  vitreous  cannot  be  absolutely  avoided.  A  great  advantage 
of  this  operation  is  that  the  surgeon  is  able  to  move  the  needle  in  a 
larger  area  of  excursion  than  when  the  needle  must  be  pushed  through 
the  cornea  into  the  deep  anterior  chamber  in  a  perpendicular  direction. 
The  latter  procedure  leaves  very  little  freedom  of  motion  to  make  the 
incision.  After  discission  through  the  sclera,  complications  such  as 
increase  of  intraocular  pressure  and  cyclitis  frequently  occur. 
The  former  usually  disappears  within  a  few  days  under  the  use  of 
eserin  and  cold  compresses.  In  most  cases  the  cyclitis  is  also  a  transient 
phenomenon. 

LINEAR  EXTRACTION. 

Linear  extraction  is  an  operation  employed  for  the  removal  of  soft 
cataracts.  The  thirty-fifth  year  is  approximately  about  the  upper 
age  limit  at  which  this  operation  can  still  be  performed. 

After  dilatation  of  the  pupil  by  atropin,  a  linear  incision  about 
6  to  8  mm.  long  is  made  with  the  lancet  below  and  exactly  at  the  limbus. 
Sitting  to  the  right  of  the  patient  the  operation  is  performed  on  the 
right  eye  as  well  as  the  left  with  the  right  hand.  Essentially  the  same 
rules  described  for  the  iridectomy  incision,  are  the  guide  in  holding 
the  lancet  (Fig.  93).  It  is  first  applied  rather  perpendicularly,  and 
as  soon  as  the  point  has  perforated  the  limbus,  the  blade  is  turned 
parallel  to  the  iris  (Fig.  94),  and  without  either  forward  or  backward 
pressure,  pushed  in  until  the  incision  has  reached  the  desired  length. 
If  the  iris  is  well  retracted,  it  is  not  exposed  to  any  danger  of  injury. 
As  with  all  cuts  which  open  the  anterior  chamber,  the  instrument  must 
not  stop  in  its  progress,  otherwise  escape  of  the  aqueous  humor  would 
render  impossible  a  further  lengthening  of  the  incision.  The  eye  is 
held  fast  at  any  suitable  point.  As  the  operation  is  performed  without 
iridectomy,  the  point  at  which  the  eye  is  grasped  with  the  forceps  for 
the  purpose  of  fixation  plays  no  r61e.  The  lancet  is  slowly  withdrawn 


SECONDARY    CATARACT.       IRIDOTOMY. 


175 


from  the  eye  so  that  the  aqueous  humor  escapes  gradually.  At  the 
moment  the  anterior  chamber  collapses,  the  pupil  frequently  becomes 
suddenly  narrow.  In  other  cases,  however,  the  iris  is  floated  into  the 
wound  by  the  aqueous  humor. 

The  second  step  of  the  operation  consists  in  opening  the  lens- 


Fir..  93. — Linea  extraction  in  the  right  eye.  The  operator's  left  hand  fixes  the  eye 
with  a  pair  of  forceps,  above  at  the  limbus,  while  with  the  right  hand  he  applies  the  lancet 
almost  vertically  below,  exactly  at  the  limbus.  The  pupil  is  dilated  by  atropin.  A  diagram 
showing  the  position  of  the  incision  in  this  operation  may  be  seen  in  the  sketch  (;n  glauo  ma 
(Fig.  96). 

capsule.  Here  also  we  prefer  the  use  of  the  capsule-forceps  for  the 
reasons  mentioned  in  Chapters  XI  and  XII.  They  must  be  slightly 
raised  after  they  have  entered  the  pupil,  so  that  the  posterior  untoothed 
part  of  the  closed  blades  does  not  seize  the  iris.  With  a  relatively  short 
incision  and  a  narrow  pupil  it  may  be  difficult  to  use  the  forceps  without 
untoward  results,  and  the  pointed  tenaculum,  which  must  always  be 


i76 


OPHTHALMIC    SURGERY. 


at  hand,  is  to  be  employed  to  incise  the  capsule  several  times.  In 
so  doing  the  tenaculum  must  be  applied  without  making  pressure, 
in  order  to  avoid  displacement  of  the  lens. 


§3 

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The  third  step  of  the  operation,  the  removal  of  the  lens,  is  accom- 
plished easily.  If  the  cataract  is  soft,  it  suffices  to  merely  depress  the 
scleral  wound-margin  slightly  by  means  of  the  spoon,  in  order  to 


SKCONDARY    CATARACT.        I  K  1 1  ><  >T< )  M  Y  .  I  77 

allow  the  soil  mass  to  sli<U-  out  through  tin-  gaping  wound.  If.  at  the 
same  time,  the  cataract  is  gcntlv  stroked  from  above  downward  with 
another  spoon  against  the  eornea  (Fig.  95).  the  escape  of  the  lens- 
substance  will  be  rendered  easier.  Occasionally,  after  the  pupil  has 
become  black,  new  opaque  particles  appear  from  above  and  behind 
tlie  iris  as  the  result  of  this  gentle  massaging.  These  must  be  removed 
through  the  wound  by  further  massage. 

Diiliculties  in  the  removal  of  the  lens-substance  occur  only  when 
the  lens  unexpectedly  contains  a  fairly  large  nucleus,  which  presses 
against  the  wound  and  cannot  be  forced  through  safely,  since-  no  great 
torce  dare  be-  used  in  the  massaging.  A  rather  dense  nucleus  may  be 
found  even  in  young  people.  In  these  cases  it  is  better  to  lengthen 
the  incision  at  one  or  both  ends  by  means  of  the  scissors,  allowing  the 
nucleus  to  escape  easily,  rather  than  to  run  the  risk  of  a  prolapse  of  the 
vitreous  by  applying  too  strong  pressure.  A  careful  replacement 
of  the  iris  concludes  the  operation. 

In  this  type  of  operation  care  of  the  iris  requires  the  most  careful 
consideration.  This  delicate  membrane  must  not  be-  injured  either 
during  the  incision  or  in  opening  the  capsule  of  the  lens,  nor  disturbed 
too  much  in  massaging  out  of  the  cataractous  mass  with  the  spoon. 
Care  should  also  be  taken  to  avoid  injury  in  replacing  it  with  the 
sj  alula.  A  lorn  iris  may  give  rise  to  most  unpleasant  sequehc.  by 
shrinking  or  by  adhering  to  the  corneal  scar.  If  the  iris  has  been 
considerably  injured  it  should  be  excised.  The  resultant  coloboma 
lying  exposed  in  the  palpebral  fissure,  however,  causes  annoying  visual 
disturbances.  As  the  operation  usuallv  passes  off  smoothly,  the 
incision  below  is  preferable,  because  the  patients  more  readily  look 
upward,  and  so  freely  expo-e  the  field  of  operation.  If  performed 
near  the  specified  age-limit,  it  is  better  to  make  the  corneal  incision 
above,  so  that  in  the  event  of  a  large  nucleus  the  wound  can  be  length- 
ened and  the  iris,  should  it  prolapse,  excised. 

After  the  operation  a  dressing  is  applied  and  the  patient  put  to  bed. 
It  is  not  nccessarv  to  instil  e-erin  as  it  would  have  no  inthi'Tice.  the  iris 
being  under  atropin.  If  no  complications  have  occurred,  the  dressing 
may  be  discarded  after  six  days. 

In  old  and  complicated  cataracts  the  len>  capMi'.e  is  thickened,  and 
it  may  happen  that  the  lens  together  with  its  capsule  i-  pulled  out  of 
the  eve  with  the  cupsuk'-forceps.  Occa-ionall\  such  an  operation  is 
performed  in  blind  eves,  but  onlv  for  cosmetic  reason-.  In  this 


1 78 


OPHTHALMIC    SURGERY. 


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SECONDARY    CATARACT.       IRIDOTOMY.  179 

procedure  there  is  always  the  danger  of  prolapse  of  the  vitreous. 
However,  as  the  vitreous  rarely  has  its  normal  consistency,  but  is 
fluid  and  the  eyeball  soft,  the  wound  shows  no  tendency  to  gape,  and 
the  iris  usually  retains  its  normal  position.  Much  more  unpleasant 
is  prolapse  of  vitreous  of  normal  consistency  during  the  course  of  a 
linear  extraction.  In  this  instance,  not  only  is  the  further  removal 
of  the  soft  lenticular  mass  prevented,  but  no  replacement  of  the  iris 
can  be  attempted,  and  the  pupil  remains  permanently  distorted. 
Moreover,  the  wound  frequently  gapes,  and  has  its  healing  process 
interfered  with  by  the  lower  lid  pressing  against  it  during  the  ocular 
movements.  Application  of  a  suture  to  produce  coaptation  of  the 
edges  of  the  wound  may  become  indispensable. 

Linear  extraction  near  the  lower   age-limit  has  already  been 
discussed. 


CHAPTER  XV. 
GLAUCOMA. 

IRIDECTOMY. 

The  incision  for  iridectomy  in  glaucoma  does  not  penetrate 
the  sclera  at  the  limbus,  but  i^  mm.  behind  it.  The  line  cd 
(Fig.  96)  shows  the  direction  of  the  penetration  of  the  point  of  the 
knife,  the  lancet  applied  vertically  to  the  sclera.  This,  however,  is  only 
possible  if  the  angle  of  the  anterior  chamber  is  deep.  If  the  chamber 
is  shallow,  or  if  the  iris-root  is  in  contact  with  the  posterior  wall  of  the 


FIG.  96 — Anterior  portion  of  the  eyeball  in  cross-section  to  demonstrate  the  relations  in 
position  of  the  angle  of  the  chamber  and  limbus  (enlarged).  The  limbus  reaches  about  2mm. 
further  forward  than  is  represented  by  the  situation  of  the  angle  or  the  chamber,  a  and 
a';  limbus.  ab  and  a'b';  position  for  the  incision  of  the  extraction.  Graefe's  knife,  which 
in  cataract  incisions  is  inserted  just  at  the  limbus,  at  a,  perforates  the  posterior  wall  of 
the  coi  nea  at  b.  In  order  that  the  knife  shall  come  out  exactly  again  at  the  limbus  at  a', 
the  counterpuncture  must  be  begun  already  at  b',  that  is,  at  a  point  which  to  the  oper- 
ator seems  to  lie  about  i  mm.  from  the  limbus,  in  the  direction  toward  the  cornea. 

cornea,  an  injury  to  the  iris  would  be  unavoidable.  Moreover,  as  in  such 
a  puncture  the  inclination  to  bring  the  lancet  into  the  plane  of  the  iris 
is  very  strong,  it  is  recommended  not  to  apply  it  too  vertically  against 
the  sclera  when  making  the  puncture. 

The  Incision  with  the  Lancet. — As  it  is  the  intention  to  extirpate 
the  iris  at  its  ciliary  attachment  the  incision  must  lie  in  the  sclera  at 
a  distance  of  about  i  to  IY  mm.  from  the  limbus,  the  instrument  being 
carried  through  the  angle  of  the  anterior  chamber,  the  relations  of  which, 

1 80 


GLAUCOMA. 


iSl 


as  pointed  out  in  the  operation  for  cataract,  render  clear  the  situation 
of  the  scleral  incision.  If,  therefore,  the  incision  is  made  with  the 
lancet,  its  point  must  be  placed  against  the  sclera  at  the  distance 
named,  the  blade  forming  an  angle  of  about  45°  to  the  curving  of  the 
sclera  (Fig.  97).  The  lancet  is  held  in  the  right  hand  between  the 


FIG.  97. — Iridectomy  for  glaucoma  in  the  left  eye.  Beginning  of  the  incision.  The 
assistant  fixes  the  upper  lid  with  one  finger  of  his  right  hand  in  such  a  manner  that  the 
operator  is  not  interfered  with  in  the  second  act  of  the  incision,  when  the  position  of  the 
lancet  is  changed.  The  lancet  is  applied  slantingly  against  the  sclera  at  a  distance  of  at 
least  i  mm. 


thumb  and  first  and  second  fingers,  while  the  little  finger  is  steadied 
against  the  head  of  the  patient,  the  operator  sitting  on  the  right  side 
of  the  patient.  The  eyeball  is  fixed  below,  exactly  in  the  vertical 
meridian,  as  in  the  operation  for  cataract,  so  that  the  coloboma  is 
directed  upward.  An  undesirable  laterally  situated  cut  and  correspond- 


182 


OPHTHALMIC    SURGERY. 


ing  coloboma  is  the  result  of  rotation  of  the  eye  if  the  forceps  holds 
the  ball  at  the  side.  The  patient  himself  should  look  well  down- 
ward during  the  incision.  .  In  the  slanting  position  the  point  of  the 
lancet  is  made  to  penetrate  the  sclera. 

Immediately  after  the  perforation  the  lancet  is  turned  so  that  the 


FIG.  98. — The  position  of  the  lancet  is  changed  to  the  plane  of  the  iris  and  is  held  so 
that  the  incision  on  all  sides  has  the  same  distance  from  the  limbus.  The  lancet  penetrates 
further  downward,  than  is  shown  in  the  figure. 

surface  of  the  blade  is  parallel  with  the  iris  (Fig.  98).  The  turning  of 
the  lancet  at  the  proper  time  is  the  most  difficult  part  of  the  incision, 
and  can  be  told  only  by  the  sense  of  touch,  as  after  completion  of  the 
perforation  the  resistance  of  the  ocular  tunics  disappears.  If  the 
direction  of  the  knife  is  changed  too  soon,  the  cut  is  made  irregularly, 


GLAUCOMA.  183 

and,  what  is  still  worse,  placed  too  far  forward  into  the  cornea,  and  the 
internal  opening,  instead  of  being  placed  into  the  angle  of  the  chamber, 
is  found  nearer  the  cornea.  After  the  knife  enters  the  eye,  and  its 
surface  is  parallel  with  the  iris,  it  is  pushed  downward  without  inter- 
ruption, until  the  point  passes  the  lower  border  of  the  pupil,  and  the 
cut  is  as  large  as  needed  (Fig.  100).  In  this  maneuver  the  point  of 
the  lancet  naturally  approaches  near  to  the  posterior  surface  of  the 
cornea.  During  the  incision  the  lancet  must  not  be  pressed  back- 
ward against  the  sclera,  as  the  wound  will  gape  and  the  aqueous 
humor  flow  away,  thus  making  prolongation  of  the  incision  impossible, 
as  through  it  the  iris  and  lens  would  most  likely  be  injured.  As  in 
all  other  incisions  which  open  the  anterior  chamber, 
any  withdrawal  of  the  instrument  while  making  the 
cut  is  absolutely  forbidden,  as  this  would  frustrate 
the  further  progress  through  the  escape  of  the 
aqueous. 

The   incision   must  be  made  parallel  to  the  limbus. 
(Fig.   99   ab}.     For  this  purpose  the  lancet  itself 
must  be  held  parallel  to  the  same.      If,   for  ex 
ample,  one  edge  of  the  knife  is  turned  slightly  for-  The  solid  line  ab  de- 

•      ,  ,,.        .,          .,,  .  ,       notes    the    position    of 

ward,  the  cut  on  this  side  will  not  remain  at  the  the  cut. 
same  distance  from  the  limbus  at  which  the  point 
of  the  lancet  was  first  placed,  but  will  deviate  forward  into  the  cornea. 
Indeed,  the  difficulty  of  the  incision  with  the  lancet  lies  in  the  fact 
that  the  eye  of  the  operator  must  at  the  same  time  control  the  point  of 
the  instrument  penetrating  more  and  more  downward,  and  also  the 
appearance  of  the  cut  above  at  the  limbus.     When  the  lancet  has 
entered  far  enough  downward,  and  the  incision,  therefore,  has  been 
made  long  enough,  the  instrument  is  slowly  withdrawn  from  the  eye, 
with  the  blade  parallel  to  the  iris. 

Especially  the  point  must  on  no  account  be  turned  backward,  as  other- 
wise the  lens-capsule  will  be  injured  while  passing  the  pupil.  One 
can  avoid  the  latter  altogether  by  a  slight  sideward  movement  of  the 
point  of  the  lancet  and  thus  carry  it  upward  in  front  of  the  iris.  In 
withdrawing  the  lancet  we  do  not  increase  the  length  of  the  incision, 
as  practised  by  some  operators,  by  pushing  the  lancet  somewhat  forward 
along  the  side  of  the  limbus.  During  the  withdrawal  of  the  knife  the 
aqueous  humor  may  rapidly  escape,  and  float  the  iris  forward  with  it, 
or  the  flow  may  be  slow;  the  pupil  then  remains  round. 


184  OPHTHALMIC    SURGERY. 

The  Incision  with  the  Graefe  Knife. 

As  regards  fixation  of  the  eye  and  the  employment  of  the  right  or 
left  hand,  the  same  rules  apply  as  in  the  operation  for  cataract,  the 
operator  sitting  at  the  right  side  of  the  patient.  Only  on  the  right  eye, 
if  the  anterior  chamber  is  very  shallow,  it  may  be  preferable  to  operate 
from  behind,  as  in  this  position  the  right  hand  can  be  steadied  on  the 
head  of  the  patient  better  than  the  left  when  operating  from  the  front. 
The  length  of  the  incision  should  be  the  same  as  when  the  lancet  is 
used,  about  8  mm.  To  obtain  a  sufficiently  peripheral  position,  the 
knife-point  is  entered  in  the  sclera  at  a  distance  of  ii  mm.  from  the 
limbus.  It  is  passed  through  the  sclera  approximately  parallel  to  the 
plane  of  the  iris.  If  held  more  upright  against  the  sclera,  an  injury  to 
the  iris,  and  indeed  even  to  the  lens,  is  easily  incurred.  After  the  point 
of  the  knife  has  appeared  in  the  angle  of  the  chamber,  the  instrument  is 
pushed  forward  to  the  outermost  part  of  the  opposite  angle,  always 
remaining  in  front  of  the  iris  to  avoid  the  pupil,  and  the  counterpuncture 
is  made  ii  mm.  from  the  limbus.  The  knife  is  carried  upward  with  a 
sawing  motion,  during  which  it  is  held  in  a  plane  parallel  with  the  iris, 
so  that  the  incision  remains  at  a  uniform  distance  from  the  limbus 
throughout.  Not  until  the  knife  has  arrived  beneath  the  conjunctiva, 
is  its  cutting  edge  turned  forward  to  form  the  short  conjunctival  flap, 
as  in  the  cataract-operation. 

The  incision  must  be  made  with  the  Graefe  knife :  i.  If  the  an- 
terior chamber  is  very  shallow.  2.  If  the  pupil  is  dilated.  3.  If  the 
cornea  is  so  opaque  as  to  prevent  the  operator's  view  of  the  path  of  the 
knife.  4.  In  restless  patients.  Before  an  iridectomy  for  glaucoma  the 
pupil  should  be  contracted  as  much  as  possible  by  energetic  use  of  eserin, 
which,  however,  is  often  without  effect  when  the  pressure  is  consider- 
ably increased  and  advanced  atrophy  of  the  iris  is  present.  Alypin 
is  used  for  anesthetization,  instead  of  cocain,  because  the  former  pro- 
duces no  dilatation  of  the  pupil.  The  lack  of  vaso-constrictor  influence 
can  be  remedied  by  the  stimultaneous  administration  of  adrenalin. 

The  incision  with  the  lancet  has  the  advantage  that  its  edges  are 
smooth  and  easily  apposed,  so  that  after  a  few  days  the  wound  has  closed 
faultlessly,  in  fact,  the  scar  is  often  scarcely  visible.  The  incision 
with  the  knife  is  more  inclined  to  gape,  and,  on  account  of  its  irregular 
edges,  does  not  heal  so  promptly.  But  this  factor  may  be  considered 
as  an  advantage  in  eyes  with  an  increase  of  pressure,  inasmuch  as 
fluid  will  ooze  out  more  easily  and  for  a  longer  time  through  a  wound 


\vhich  does  not  close  rapidly  than  through  one  \vhich  heals  promptly 
and  solidly. 

There  are  a  number  of  important  disadvantages  of  the  incision 
with  the  lancet.  The  lancet  is  an  extraordinarily  sensitive  instru- 
ment. The  previously  faultless  point  may  be  injured  even  by  simple 
boiling.  Much  pressure  is  not  permissible  while  perforating  the  sclera 
with  the  lancet.  A  good  cutting  point  glides  easily  into  the  sclera 
without  much  resistance.  If.  however,  the  point  is  slightly  bent  or  not 
sufficiently  sharp,  it  would  be  a  mistake  to  try  to  make  the  perforation 
with  force.  For,  at  the  moment  when  the  damaged  point  has  penetrated, 
and  the  good  cutting  lateral  portions  of  the  instrument  are  engaged,  the 
instrument  suddenly  slips  forward  and  injury  to  the  iri>  and  lens  is 
scarcely  avoidable.  The  same  accident  may  take  place  also  while 
making  the  incision  with  the  lancet,  when  a  nervous  patient  suddenly 
makes  a  brisk  movement  with  the  eye  or  head.  The  knife  is  undoubt- 
edly much  less  dangerous,  especially  for  the  beginner,  and  a  more  peri- 
pheral position  is  more  easily  attained  with  it  than  with  the  lancet. 
On  this  account  the  lancet  is  only  used  in  those  cases  in  which  the 
anterior  chamber  is  not  too  shallow,  and  those  with  a  cor.tracted  pupil, 
when  quiet  behavior  of  the  patient  is  probable. 

\Yhile  the  performance  of  the  incision  with  the  knife  lessens  some- 
what the  danger  of  injuring  the  iris  and  lens  through  too  rapid  and  too 
deej)  penetration,  it  occasionally  leads  to  the  opposite  error  -the 
intralamellar  incision.  The  experienced  operator  at  once  recogni/.es 
the  false  position  of  the  knife  through  the  persisting  resistance,  which 
otherwise  disappears  as  soon  as  the  anterior  chamber  is  opened.  Also, 
a  retraction  of  the  cornea  is  visible  at  the  site  of  the  knife,  when  it 
is  being  pressed  backward  slightly.  As  already  stated,  the  cut  may  be 
repeated  at  once  at  the  proper  point,  if  the  anterior  chamber  has  not 
been  opened,  provided,  however,  that  the  aqueous  humor  is  still 
there.  In  the  latter  case,  nothing  re-mains  except  to  postpone  the 
operation  until  the  next  day. 

The  excision  of  the  iris  is  performed  with  the  instruments  already 
described  in  the  operation  for  cataract  the  iris  forceps  and  deWecker's 
forceps- scissors.  The  iris  forceps  are  held  in  the  left  hand  and 
introduced  closed  into  the  wound  parallel  to  the  iris  until  they  reach 
nearly  to  the  upper  margin  of  the  pupil.  They  are  then  opened 
widely  and  a  fold  of  iri>  is  drawn  up  and  pulled  out  of  the  wound. 
The  excision  is  then  quickly  completed  with  de  Wecker's  scissors. 


1 86  OPHTHALMIC    SURGERY. 

which  have  been  held  ready.  The  iris-section  is,  however,  essentially 
different  from  that  in  cataract-operation.  As  our  object  is  not  only 
to  excise  the  iris  close  to  its  attachment,  but  also  to  remove  as  large  a 
piece  as  possible,  the  scissors  are  now  held  parallel  and  closely  to  the 
wound  (Fig.  100),  which  may  even  become  slightly  depressed  by  them, 
and  the  iris  has  to  be  severed  by  making  two  cuts.  The  right  half  of 
the  iridal  fold  is  cut  through  first,  after  which  the  rest  of  the  iris,  is 
drawn  with  the  forceps  still  further  toward  the  other  angle  of  the 

wound,  thus  pulling  still  more  membrane 
from  the  eye,  and  then  the  left  half  cut 
through.  As  the  excision  of  the  iris 
is  ordinarily  quite  painful,  it  should  be 
done  as  quickly  as  possible.  The  scis- 
sors, therefore,  must  be  prepared  and 
ready  close  to  the  wound  as  soon  as  the 
iris  is  grasped. 

The   Reposition. — After    the    iris   is 
excised,    it     lies   in    most    instances    in 
both    angles    of    the  wound    or   is,    at 
FIG.  loo.— The  iris  drawn  out  from     \ea&*    squeezed    into    them.     An   accu- 

tne  eye  is  cut  off  near  its  attachment 

by  the  scissors,  the  blades  of  which     rate   reposition  is    all  the  more  impor- 

are  held  parallel  with  the  limbus.        tant?    because    a    healing    in    of    the    iris 

in  situ  would  likely  lead  to  a  renewed  attack  of  glaucoma.  It  is 
much  more  difficult  to  effect  reposition  than  in  the  operation  for 
cataract,  but  is  accomplished  in  exactly  the  same  manner  (see  p.  138). 
The  greater  difficulty  is  due  to  the  relatively  higher  pressure  which 
squeezes  the  margins  of  the  coloboma  into  the  angles  of  the  wound  more 
than  in  the  cataract-operation,  and,  as  the  iris  is  frequently  in  a  state  of 
atrophy,  it  shows  but  little  tendency  to  resume  its  normal  position. 
Reposition  is  a  very  delicate  operation,  as  the  spatula  occasionally  in- 
jures the  lens-capsule.  It  should,  therefore,  be  the  aim  to  avoid  touch- 
ing this  membrane.  The  spatula  must  be  withdrawn  from  the  eye  in 
the  neighborhood  of  the  coloboma,  after  the  operator,  coming  from 
the  angle  of  the  chamber,  has  stroked  the  sphincter  edges  into  their 
proper  position.  Care  should  be  taken  not  to  press  the  iris  up  again. 
Attempts  at  reposition  are  not  be  discontinued  until  after  both  sphincter- 
margins  have  been  returned  to  their  normal  position.  As  in  the  opera- 
tion for  cataract,  the  last  step  of  this  procedure  consists  in  attention 
to  the  proper  position  of  the  conjunctival  flap. 


GLAUCOMA.  187 

The  indications  for  iridectomy  are  primary  glaucoma,  as  well  as 
cases  of  secondary  glaucoma  which  are  not  of  a  transient  nature,  as, 
for  instance,  increase  of  pressure  caused  by  anterior  synechiae,  exclusion 
of  the  pupil  following  iritis,  luxation  of  the  lens,  cysts  of  the  iris,  begin- 
ning ectasia  of  the  conjunctiva  or  sclera,  etc. 

The  complications  which  may  arise  in  the  course  of  an  iridectomy 
for  glaucoma  have  mostly  been  described  in  the  operation  for  cataract, 
and  need  only  brief  mention  here.  The  most  important  are: 

1 .  Laceration  of  the  conjunctiva  when  grasped  by  the  forceps. 

2.  Intralamellar  incision. 

3.  Transfixion  of  the  iris  by  Graefe's  knife.      If  the  anterior  chamber 
is  shallow,  the  point  of  the  knife  may  catch  in  a  protrusion  of  the  sur- 
face of  the  iris  and  penetrate  its  tip.     This  piercing  of  a  few  fibers  of 
the  iris  with  the  knife  is  of  no  significance,  as  they  are  always  cut  through 
during  the  continuation  of  the  operation,  so  that  the  freed  iris  again 
resumes  its  normal  position.     As  in  all  other  incisions  which  open  the 
anterior  chamber,  it  should  be  considered  the  cardinal  rule  never  to 
withdraw  the  knife  with  the  intention  of  freeing  it. 

The  escape  of  aqueous  humor  at  the  moment  of  withdrawal  makes  a 
continuation  of  the  incision  impossible.  The  only  indication  for  the 
withdrawal  of  the  knife  is  when  the  operator,  while  introducing  the 
knife,  gets  in  back  of  the  iris.  In  this  case,  if  the  faulty  incision  were 
continued,  even  more  extensive  injuries  to  the  iris  and  lens  would 
occur  than  after  immediate  withdrawal  of  the  knife.  As  the  incision 
is  relatively  much  shorter  than  that  in  cataract-extraction,  and  is 
ordinarily  above  the  region  of  the  pupil,  "a  falling  of  the  iris  in  the 
way  of  the  knife"  is  an  extraordinarily  rare  occurrence  in  spite  of  the 
shallow  chamber. 

4.  Production   of   an   Iridodialysis   during   the   Incision  with   the 
Lancet. — If   the  point  of   the  lancet   catches  in  the  iris,  the   latter 
may  be  drawn  down  and  thus  torn  off  at  its  ciliary  attachment.     This 
unpleasant  occurrence  is  usually  followed  by  an  intense  hemorrhage, 
which  will  greatly  impede  the  further  course  of  the  operation,  especially 
as  it  is  difficult  to  pull  the  severed  piece  of  iris  out  with  the  forceps 
without  endangering  the  exposed  lens-capsule.     It  is  safer  to  employ 
the  blunt  hook  for  pulling  out  the  iris  instead  of  the  forceps. 

5.  The  possibility  of  injuring  the  lens  when  introducing  the  lancet 
has  already  been  considered. 

6.  Incorrect  position  of  the  incision  is  due  to  a  faulty  manner  of 


1 88  OPHTHALMIC    SURGERY. 

holding  the  knife  (turning  the  cutting  edge  forward)  or  through 
improperly  inserting  the  point  of  the  knife.  A  cut  directly  forward 
against  the  cornea  naturally  lessens  the  likelihood  of  excision  of  the 
iris  to  its  root.  Especially  to  be  avoided  is  too  long  an  incision,  which 
may  be  produced  by  introducing  the  knife  too  low  down.  The 
high  intraocular  pressure  would  cause  the  wound  to  gape  and  the  lens 
to  appear  in  the  wound. 

Complications  in  the  Course  of  the  Iridectomy  Itself.— The 
excision  of  the  iris  for  glaucoma  is  on  the.average  much  more  painful 
than  that  done  in  cataract-extraction.  The  influence  of  the  anesthetic 
is  much  slighter  on  account  of  the  injection  of  the  eye,  and  perhaps 
also  because  of  the  alteration  in  transfusion-conditions.  It  is  our 
custom,  therefore,  after  the  incision  to  instil  several  drops  of  a  sterile 
3  per  cent,  solution  of  cocain  upon  the  wound,  which,  by  direct  contact, 
appreciably  reduces  the  sensitiveness  of  the  iris.  The  extreme  suscep- 
tibility of  the  iris  to  pain  complicates  the  operation,  as,  during  the 
excision,  tearing  loose  of  the  membrane  from  its  attachment,  and  even 
pulling  out  of  a  large  piece,  may  occur  if  the  patient  suddenly  gives 
a  vigorous  jerk,  just  as  the  operator  takes  hold  of  the  iris  with  the 
forceps. 

Especial  care  is  required  in  using  the  forceps  to  bring  the  iris 
forward  to  prevent  injury  of  the  lens-capsule.  They  should  be 
introduced  into  the  wound  parallel  with  the  iris  and  pushed  close  to 
the  margin  of  the  pupil,  but  not  brought  within  the  pupillary  space 
itself.  If  the  iris  has  already  floated  into  the  wound,  the  forceps 
must  not  be  pushed  into  the  interior  of  the  eye  at  all;  but  should  lift 
up  the  exposed  iris,  which  becomes  plainly  visible  after  the  conjunctival 
flap  has  been  laid  back  on  the  cornea.  Should  the  patient  not  look 
well  downward,  the  excision  of  the  iris  may  become  difficult  and  the 
danger  of  injury  to  the  lens-capsule  increased;  especially  if  he  keeps 
moving  his  eyes  around,  or  suddenly  looks  up,  while  the  forceps  are 
in  the  eye.  In  such  cases  it  is  better  to  fix  the  eye  with  forceps,  which 
ordinarily  we  avoid  in  doing  iridectomy.  Instead  of  the  iris-forceps 
it  may  be  necessary  to  draw  out  the  iris  with  a  blunt  hook  which  has 
been  bent  in  a  suitable  direction.  It  is  self-evident,  that  we  occasionally 
must  be  content  with  the  excision  of  a  small  piece  of  the  iris,  the  re- 
moval of  a  large  one,  under  the  circumstances,  being  inadvisable  or 
impossible. 

Iridectomy  may  be  difficult  if  the  iris  is  atrophic  and  so  friable 


GLAUCOMA.  189 

that  the  forceps  tear  out  at  each  attempt  to  grasp  it.  The  iridectomy 
is  also  complicated  in  well-advanced  glaucoma  by  the  fact  that  the 
upper  half  of  the  iris  is  sometimes  so  small  that  it  disappears  behind 
the  limbus.  In  such  cases,  we  make  the  coloboma  below,  as  the  iris 
is  ordinarily  somewhat  broader  there.  The  disturbance  to  vision 
due  to  the  uncovered  coloboma  is  of  no  importance,  as  the  eyes  have 
already  been  seriously  damaged  by  the  glaucoma. 

The  earlier  the  iridectomy  in  glaucoma,  the  easier  the  operation. 
As  long  as  the  anterior  chamber  is  not  too  shallow,  and  the  iris  almost 
normal,  the  production  of  a  large  coloboma  is  possible.  As  a  result 
of  the  peripheral  situation  of  the  incision,  the  coloboma  should  reach 
to  the  attachment  of  the  iris.  Considered  technically,  the  longer  the 
operation  is  delayed,  the  harder  it  becomes  and  the  less  satisfactory 
the  result.  If  the  angle  of  the  chamber  has  been  obliterated  by 
adhesion  of  the  root  of  the  iris;  that  is,  if  it  is  displaced  further  for- 
ward, the  incision  cannot  be  made  as  near  as  desirable  to  the  periphery. 

Hemorrhage  may  become  a  disturbing  factor  in  iridectomy  for 
glaucoma.  It  may  occur  during  the  performance  of  the  incision, 
originating  either  from  dilated  conjunctival  or  anterior  ciliary  vessels 
or  as  a  consequence  of  injury  to  Schlemm's  canal.  The  anterior  cham- 
ber becomes  filled  with  blood  so  that  the  iris  is  hidden  from  view. 
At  first  we  must  try  to  remove  the  blood  from  the  eye  by  stroking  it  out, 
assisting  it  to  escape  by  slightly  depressing  the  peripheral  edge  of 
the  wound.  Usually  the  blood  reaccumulates  quickly.  It  may  be 
impossible,  however,  to  remove  the  blood,  as  it  becomes  attached  to 
the  walls  of  the  anterior  chamber  in  the  form  of  a  clot.  As  the  pupil 
cannot  be  seen,  the  lens-capsule  is  in  danger  during  the  pulling  out 
of  the  iris.  The  presence  of  the  blood  also  greatly  disturbs  the 
replacement. 

Complications  During  Reposition  of  the  Iris. — The  greater 
difficulty  in  replacing  the  iris-margins  in  this  operation  as  com- 
pared with  that  for  cataract  has  already  been  mentioned,  especially 
the  possibility  of  injury  to  the  lens-capsule.  One  may  even  be 
compelled  to  desist  from  the  replacement  if  the  patient  cannot  be 
induced  to  look  downward.  Fixation  of  the  eye  has  always  the  great 
disadvantage  that  the  wound  is  made  to  gape  and  increases  the 
likelihood  of  an  injury  to  the  lens,  the  margin  of  which  may  present 
in  the  wound.  The  necessity  of  proper  replacement  need  not  ibe 
further  enlarged  upon.  It  must,  however,  be  expressly  pointed  out, 


1 90  OPHTHALMIC    SURGERY. 

that,  when  as  the  result  of  one  of  the  margins  of  the  coloboma  growing 
fast  to  the  wound  a  renewed  increase  in  pressure  is  noted,  no  other 
procedure  is  indicated  beyond  the  freeing  of  the  adherent  iris  by 
operative  interference.  Neither  a  second  iridectomy  nor  a  sclerotomy 
nor  any  other  similar  operation  fulfills  the  indication. 

The  liberation  of  attached  iris  is  performed  in  the  following 
manner:  An  incision  is  made  with  Graefe's  knife,  which  is  inserted 
at  one  angle  of  the  scar,  carried  through  the  anterior  chamber  until 
it  reaches  the  other  side  of  the  site  of  adhesion,  and  is  then  brought 
out  as  far  in  the  periphery  as  possible.  The  incision  is  completed 
with  sawing  movements.  Frequently  the  knife  has  already  separated 
the  iris  from  the  scar,  and  the  membrane  assumes  its  proper  position 
immediately  after  the  incision  has  been  completed.  If  this  result 
is  not  secured,  the  iris  must  be  brought  out  from  the  wound  with  the 
iris-forceps,  and  as  large  a  piece  as  possible  excised.  The  cut  edges 
are  then  replaced.  Because  of  the  state  of  ocular  irritation,  this 
operation  is  often  difficult  of  performance,  but  is  usually  followed  by  a 
favorable  result.  The  blackish  scar,  which  has  been  ectatic,  soon 
flattens  out  during  healing,  and  the  increase  in  pressure  does  not  recur. 

This  operation  is  also  indicated  in  adherent  iris  after  cataract- 
operations  in  which  there  has  been  an  increase  in  tension.  In  order 
to  prevent  a  gaping  of  the  wound  and  a  prolapse  of  the  vitreous,  it  is 
recommended  to  leave  a  bridge  of  conjunctiva  and  then  bring  the  iris 
out  under  it.  By  the  same  method  one  has  to  remove  the  so-called 
cystic  scars  after  cataract-operations. 

Prolapse  of  the  vitreous  is  a  relatively  rare  occurrence  in  iri- 
dectomy for  glaucoma.  It  is  most  likely  to  happen  in  old  absolute 
glaucoma,  especially  if  there  is  ectasia  of  the  sclera.  The  prolapse  not 
only  makes  excision  of  the  iris  impossible,  but  also  a  reposition  of  its 
margins.  Besides,  the  wound  gapes  because  of  the  interposition  of 
the  vitreous,  and,  although  an  ugly  ectatic  scar  is  formed,  it  is  one  of 
the  relatively  good  outcomes  of  the  operation.  In  most  instances 
renewed  attacks  of  increase  in  pressure  follow,  which,  on  account  of 
their  painfulness,  finally  render  enucleation  of  the  eye  compulsory. 
Occasionally  the  vitreous  prolapse  leads  to  a  still  graver  complication, 
namely,  expulsive  hemorrhage.  On  account  of  the  sudden  decrease 
in  pressure,  severe  hemorrhages  under  the  chorioid  occur,  which  is 
pushed  forward  with  the  retina  and  squeezed  out  of  the  eye  through 
the  wound.  Particularly  in  the  operations  for  old  absolute  glaucoma 


GLAUCOMA.  IQI 

is  this  accident  seen.  Such  eyes  must  be  immediately  enucleated; 
otherwise  weeks  would  pass  before  the  eye  atrophied  and  became 
quiescent.  The  bleeding  which  occurs  with  expulsive  hemorrhage 
is  usually  very  considerable,  and  to  arrest  it  temporarily  the  application 
of  a  pressure-dressing  is  necessary. 

Subluxation  of  the  lens  may  occur  in  connection  with  its  altered 
position  following  the  opening  of  the  anterior  chamber  and  the  escape 
of  the  aqueous  humor.  The  lens  then  inclines  forward,  and  its  upper 
border  tends  to  turn  forward  on  account  of  the  lessened  resistance  of 
the  coverings  of  the  bulb  in  the  region  of  the  wound.  This  presages 
a  bad  prognosis  for  the  later  behavior  of  the  eye.  The  anterior 
chamber  does  not  become  re-established  for  a  long  time,  intense  attacks 
of  renewed  increase  in  pressure  follow,  and  in  spite  of  repeated  sclerot- 
omies  and  other  operations  such  eyes  are  usually  lost. 

Cataract,  which  occasionally  follows  the  operation,  deserves  special 
mention.  Injuring  of  the  lens,  the  danger  of  wrhich  has  been  fre- 
quently mentioned,  occurs  in  the  region  of  the  anterior  capsule,  and  if  a 
careful  examination  is  made,  the  scar  of  the  capsule  wound,  from  which 
the  cataract  had  its  origin,  can  always  be  demonstrated.  The  cataract 
does  not  always  become  complete,  but  may  be  confined  either  to  a 
clouding  in  the  neighborhood  of  the  capsular  wound,  or  to  a  stellar 
opacity  in  the  anterior  or  posterior  lamellae  of  the  cortex. 

Occasionally  after  iridectomy  for  glaucoma  there  may  occur  a 
spontaneous  rupture  of  the  lens-capsule  in  the  region  of  the 
equator.  This  is  especially  seen  in  cases  in  which,  after  completing 
the  iridectomy,  a  subchorioidal  hemorrhage  produced  an  increase  ia 
intra-ocular  pressure,  by  which  the  lens  is  displaced  forward  and  its 
border  presents  in  the  wound.  In  this  condition  the  capsule,  being 
deprived  at  this  point  of  its  protecting  intra-ocular  pressure,  ruptures 
through  the  forward  pushing  of  the  lens-substance.  As  the  rupture 
lies  in  the  equator  of  the  lens,  no  capsule  wound  is  seen  by  lateral  illu- 
mination, and  the  clouding  of  the  lens  begins  in  the  posterior  cortical 
substance.  The  lens-capsule  may  burst  spontaneously  over  a  wide 
area  and  the  lens-substance  with  the  nucleus  be  either  discharged 
from  the  eyeball  or  become  incarcerated  into  the  wound  (Hernia 
lenlis),  which  remains  highly  gaping  under  the  conjunctiva.  Fortu- 
nately, such  cases  are  rare.  We  must  be  prepared,  however,  for  such 
accidents  in  operations  on  eyes  with  long-continued,  high-grade  in- 
crease of  pressure,  when  the  eye  is  of  stony  hardness,  the  anterior 


OPHTHALMIC    SURGERY. 


chamber  almost  obliterated,  the  sclera  becoming  ectatic,  the  iris 
markedly  atrophic  and  the  eye  itself  painful.  The  operation  often 
cannot  be  performed  without  a  general  anesthetic.  If  the  eye  is 
completely  blind,  enucleation  should  be  advised. 


niAPTKR   XVI. 
GLAUCOMA     (Continued). 

ANTERIOR  SCLEROTOMY    DE  WECKER,. 

Anterior  sclerotomy  is  done  with  a  (iraefc  cataract-knife,  and 
resembles  the  incision  made  for  the  extraction  of  a  senile  cataract, 
except  that  it  is  placed  more  peripherally.  The  opening  into  the 
anterior  chamber  mav  be  made  above  or  below,  the  eve  beintr  fixed 


Fir..  101 .  -  Anterior  sclerotomy  in  the  left  eye.-,  performed  In-low.  Beginning  of  the  inci- 
sion.  The  left  hand  of  the  operator  fixes  the  eye.  either  laterally  or  alxive;  the  rutting  edge 
of  the  knife  is  directed  downward.  The  incision  is  begun  at  least  i  mm.  away  from  the 
limhus  in  the  sclcra.  The  lower  lid  i>  drawn  far  downward  by  the  assistant. 

at  such  a  point  that  the  forceps  will  not  be  in  the  way  of  the  knife. 
As  the  operation  has  for  its  object  an  incision  into  the  an^le  of  the 
chamber,  the  points  of  entrance  and  exit  of  the  knife  must  lie  in  the 
sclcra  at  least  i  to  i  \  mm.  from  the  limbus,  according  to  the  relations 


194  OPHTHALMIC    SURGERY. 

of  the  parts  already  described.  As  the  knife  can  be  entered  only 
from  without,  the  directions  given  in  the  discussion  of  the  operation 
for  cataract  as  to  the  use  of  the  right  or  left  hand  hold  good  here 
(Fig.  101). 

As  the  anterior  chamber  is  usually  shallow  in  the  eyes  in  which 
anterior  sclerotomy  is  indicated,  the  performance  of  the  incision  is  by 
no  means  easy.  If  the  point  of  the  knife  is  thrust  through  the  sclera 
too  vertically,  the  iris  may  be  pierced  and  even  the  lens  injured.  For 
this  reason,  in  the  effort  not  to  wound  the  iris, 'the  knife  is  applied 
parallel  to  its  surface.  If  its  point  is  directed  slightly  forward,  it  is 

pushed  between  the  layers  of  the 
cornea — an  intralamellar  incision. 
Frequently  it  cannot  be  seen  that  the 
knife  is  passing  between  the  layers  of 
the  cornea,  but  the  experienced  oper- 

FIG.    102. — Diagram    showing    the  ,    ,  .-,  1  ,     , 

position  of  the  knife  in  the  eye  during  ator  detects  the  error  because  of  the 
the  incision  of  the  sclera.  it  lies  at  continued  resistance,  which  disappears 

least  i  mm.  away  from  the  limbus  in 

the  sclera.  at  once  when  the  perforation  is  made 

properly.     After  the  point  of  the  knife 

has  entered  the  angle  of  the  chamber,  it  is  slowly  carried  onward 
between  the  cornea  and  iris,  until  it  reaches  the  angle  of  the  chamber 
on  the  other  side,  where  it  is  made  to  penetrate  the  sclera,  reappearing 
at  the  same  distance  from  the  limbus  as  the  first  pucture  (Fig.  102). 
The  incision  is  continued  with  sawing  movements  as  described  in 
the  operation  for  cataract. 

In  order,  however,  to  prevent  a  prolapse  of  the  iris,  the  cut  is  not 
completed,  but  a  small  bridge  of  sclera  is  permitted  to  remain;  in  other 
words,  the  knife  is  withdrawn  from  the  eye  before  the  incision  is 
finished.  But,  as  it  is  the  intention  to  cut  into  the  angle  of  the  chamber 
of  this  portion  too,  the  handle  of  the  knife  is  depressed,  i.  e.,  raised, 
while  withdrawing  the  blade  so  that  its  point  cuts  through  the  angle 
of  the  chamber  from  within  (Fig.  103) .  The  length  of  the  entire  incision 
is  somewhat  less  than  that  of  the  cataract-incision.  We  begin,  there- 
fore, about  3  mm.  from  the  horizontal  meridian,  as  seen  in  the  illus- 
tration (Fig.  104).  Usually  after  completion  of  the  incision  the  iris 
remains  in  its  normal  position,  especially  if  the  patient  is  quiet,  but 
should  the  pupil  be  distorted  or  the  iris  prolapsed,  reposition  is  done 
according  to  the  prescribed  rules.  It  may  happen  that,  when  the 
dressing  is  changed  on  the  following  day,  the  iris  is  found  misplaced 


or  prolapsed,  in  which  case  it  is  best  to  perform  an  excision  of  the 
prolap>e. 

Accidents  may  occur  during  the  execution  of  an  anterior  sclcrotomy. 
the  most  important  of  which  are  the  following: 

i.  Intralamellar  incision,  mention  of  which  has  already  been 
made.  It  the  faulty  incision  is  discovered  before  the  anterior  chamber 
is  perforated,  it  i-  best  to  withdraw  the  knife  and  to  make  a  new 


I-' ic,.  ID}.  -Termination  of  the  incision.  In  order  to  i  ut  through  the  inner  lamella-  of 
the  sclera  in  the  neighborhood  ol  the  srleral  bridge,  which  is  permitted  to  remain,  the  knile 
is  turned  bv  an  elevation  ot  its  handle  in  such  a  manner  that  its  point  pnxluco  the  desired 
incision  into  the  angle  of  the  <  hambcr. 

Compare  the  position  of  tin  operator's  hand  holding  the  knife  while  performing  the  tir^t 
act  of  the  operation  (Fig.  ion  and  while  withdrawing  it  <  Fig.  1031. 

puncture.  If,  however,  the  aqueous  humor  has  already  escaped,  the 
operation  must  be  interrupted,  as  it  is  impossible  to  continue  it  without 
injuring  the  iris.  The  traumatic  opacity  of  the  cornea  consecutive 
to  an  intralamellar  incision  is  of  no  real  significance,  as  it  eventually 
clears  up  completely. 

2.  The  incision  may  not  lie  far  enough  in  the  periphery.     As 


we  can  expect  favorable  re- 


e opera!  ion  oniv  u 


:,  '• 


1 96  OPHTHALMIC    SURGERY. 

passes  through  the  angle  of  the  chamber,  it  is  a  serious  mistake  to 
place  it  at  the  limbus  or  in  the  cornea  itself,  except  when  the  root  of 
the  iris  is  adherent  to  the  posterior  surface  of  the  cornea,  thus  displacing 
the  angle  of  the  chamber  further  forward  and  making  it  impossible 
for  the  operator  to  begin  the  incision  to  the  outer  side  of  the  limbus, 
as  the  knife  would  then  be  carried  in  back  of  the  iris. 

3.  An  accident  occasionally  noted  in  this  operation  in  connection 
with  the  misplacement  of  the  recess  of  the  anterior  chamber  is  irido- 
dialysis,  the  knife  carried  to  the  periphery  dividing  the  iris-root 
adherent  to  the  cornea.     A  severe  hemorrhage  may  follow  this  injury. 
The  results  of  anterior  sclerotomy  are  in  the  greater  number  of 
cases  not  only  temporarily  good,  but  also  perma- 
nently lasting,  if  the  operation  is  not  used  as  the 
primary  one  in  glaucoma,  but  is   reserved   for 
cases,  in  which  after  a  formal  iridectomy  there 
is  a  renewed  increase  of  pressure.     In  such  cases 
FlG;i!04'^Ir  this  dia"     it  is  our  custom  not  to  perform  a  second  iridec- 

gram  the  solid  line  repre- 
sents the  perforating  cut,     to  my  at  once,   which,   as  it   would   have   to   be 
the  dotted  line  that  part  111-1  <•  n  i- 

of  the  incision,  in  the  made  below,  is  always  followed  by  a  severe  dis- 
range  of  which  only  the  turbance  in  the  visual  power,  but  to  place  our 

inner    lamellse     of    the 

sclera  are  cut  through.  reliance  on  an  anterior  sclerotomy.  When 
necessary  this  operation  may  be  repeated  several 
times  on  the  same  eye,  and  it  is  optional  whether  the  incision  should 
be  made  above,  below  or  at  any  other  favorable  point.  In  the  eyes 
with  a  coloboma  upward  we  prefer  to  make  the  sclerotomy  below,  to 
have  the  knife  separated  from  the  anterior  capsule  of  the  lens  by  the 
iris,  to  insure  against  a  possible  injury  of  the  capsule. 

In  this,  as  in  every  glaucoma-operation,  the  eye  must  be  energetically 
treated  with  eserin  before  the  operation,  in  order  to  bring  about  as 
marked  a  contraction  of  the  pupil  as  possible. 

Anterior  sclerotomy  is  recommended  for  simple  glaucoma,  as 
well  as  hemorrhagic  glaucoma  and  hydrophthalmos.  In  hemorrhagic 
glaucoma  it  should  be  used  as  a  preliminary  operation,  to  lower  the 
pressure,  in  order  that  an  iridectomy  may  be  performed  later  under 
less  dangerous  conditions. ' 

POSTERIOR  SCLEROTOMY. 

This  operation  consists  in  the  pucture  of  the  vitreous  space  through 
the  sclera  with  a  Graefe  cataract-knife.  In  order  to  avoid  injuring  the 


GLAUCOMA. 


197 


more  important  parts  of  the  eye,  the  following  rules  must  be  observed : 
The  perforation  of  the  sclera  is  made  posterior  to  the  ciliary  body;  that 
is,  at  least  6-7  mm.  from  the  limbus  in  the  human  eye.  As  the  nose 
interferes  with  such  a  peripheral  incision  on  the  inner  side  of  the 
eyeball,  the  operation  is  usually  performed  to  the  outer  side,  or  best 


FIG.  105. — Posterior  sclerotomy.  The  eye,  which  is  directed  well  upward  and  inward, 
is  fixed  with  forceps  at  the  limbus  and  Graefe's  knife  is  introduced  at  the  outer  and  lower 
portion  in  a  meridional  direction,  the  cutting  edge  looking  backward,  the  point  toward  the 
center  of  the  eyeball.  The  assistant  pushes  the  lower  lid  far  downward. 

at  the  outer  and  lower  portion  between  the  external  and  inferior  rectus 
muscles,  while  the  patient  looks  inward  and  upward.  The  eye  is 
fixed  with  forceps  to  prevent  any  unexpected  movement.  In  posterior 
sclerotomy  the  cutting  edge  of  the  instrument  is  directed  backward ; 
that  is,  away  from  the  ciliary  body  so  as  not  to  bring  this  organ  into 
danger.  The  incision  is  made  in  a  meridional  direction,  corresponding 
to  that  of  the  fibers  of  the  sclera  and  the  blood-vessels  in  the  chorioid. 


198  OPHTHALMIC    SURGERY. 

An  equatorial  incision,  that  is,  one  parallel  to  the  limbus,  would  divide 
a  series  of  blood-vessels  in  the  choroid.  For  the  same  reason  the  cut 
must  not  be  placed  in  the  horizontal  meridian,  because  the  posterior 
long  ciliary  artery  runs  in  this  direction.  Injury  to  this  vessel  would 
destroy  the  eye  through  a  severe  hemorrhage  into  the  vitreous. 

During  the  puncture  the  point  of  the  knife  is  directed  toward  the 
center  of  the  eyeball,  in  order  not  to  pierce  the  posterior  capsule  of 
the  lens,  which  could  readily  occur  if  the  blade  were  passed  obliquely 
forward  (Fig.  105).  Moreover,  the  puncture  must  have  a  definite 
length — as  long  as  the  breadth  of  the  knife.  In  order  to  lower  the 

tension  of  the  eye  by  the  escape  of 
a  small  amount  of  vitreous  humor, 
the  knife  must  be  turned,  while  in 
the  scleral  wound,  from  a  meridional 
direction  to  an  equatorial  one  (Fig. 
106),  so  that  the  wound  is  caused 
to  gape.  After  the  knife  has  been 

FIG.  106.— in  this  diagram,  the  knife,  returned  to  its  original  position,  it 
which  is  now  in  the  eyeball,  is  turned  to  is  withdrawn  from  the  eye. 

the  equatorial  direction,  so  that  the  wound 

gapes  allowing  the  vitreous  to  exude.  Indications. — Posterior      Sclero- 

tomy  is  of  small  value  as  an  opera- 
tion for  glaucoma,  as  the  diminution  of  pressure  induced  by  it  usually 
soon  disappears,  sometimes  after  a  few  hours,  and  the  scar  which  is 
later  to  be  met  with  at  the  site  of  the  incision  is  so  dense  that  a  nitra- 
tion of  the  ocular  fluids  outward  cannot  take  place.  Hence,  posterior 
sclerotomy  is  used  in  glaucoma  only  as  a  preliminary  operation  in  cases 
in  which  iridectomy  is  technically  impossible  because  of  the  complete 
obliteration  of  the  anterior  chamber  in  the  presence  of  enormous 
increase  in  pressure.  In  most  cases  an  iridectomy  may  be  proceeded 
with  immediately  after  the  posterior  sclerotomy,  as  the  escape  of  the 
vitreous  produces  a  softening  of  the  eyeball  and  simultaneously  the 
anterior  chamber  commences  to  reappear.  Posterior  sclerotomy  is 
further  employed  in  puncturing  the  sub-retinal  space  in  detachment 
of  the  retina.  In  such  cases  the  operation  must  often  be  repeated, 
and,  according  to  Deutschmann,  may  be  associated  with  perforation  of 
the  retina  itself.  Good  results  are  unfortunately  not  to  be  expected. 
The  principal  value  of  posterior  sclerotomy  lies  in  the  possibility  of 
employing  it  as  an  accessory  operation  in  the  removal  of  foreign  bodies 
from  the  vitreous  chamber,  as  will  be  found  described  elsewhere. 


GLAUCOMA. 


I99 


CYCLODIALYSIS  (HEINE). 

The  Operation. — Cyclodialysis,  invented  by  Heine,  is  executed  in 
the  following  manner:     While  the  patient  looks  upward,  an  incision 


U    &>    3 
•££='-' 

<  5  o 


111 

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bi 


is  made  with  the  scissors  into  the  conjunctiva  at  its  outer  and  lower 
part,  at  a  distance  of  about  5  mm.  from  the  limbus,  and  the  sclera 


200 


OPHTHALMIC    SURGERY. 


exposed  by  undermining.     An  assistant  holds  the  wound  open  with 
two    double   tenacula,    and    a   cut    2    mm.   long    is    made   with    the 


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lancet  vertically  through  the  sclera  at  a  distance  of  5  mm.  from  the 
limbus  and  parallel  to  it  (Fig.  107),  the  eye  being  fixed  with  forceps. 


GLAUCOMA.  201 

As  the  ciliary  body,  which  lies  immediately  beneath,  must  not  be 
injured,  we  must  proceed  very  cautiously  with  the  cutting,  and  slowly 
divide  the  tissues  layer  by  layer,  until  the  black  of  the  uvea  appears 
in  the  wound.  The  incision  is  not  made  with  the  point  of  the  knife, 
but  with  one  of  its  lateral  edges,  so  that  the  same  depth  is  kept  in  the 
entire  length  of  the  wound. 

Xext  a  spatula,  such  as  is  used  in  reposition  of  the  iris,  under  con- 
tinuous fixation  of  the  eye  is  carefully  carried  forward  through  the 
wound  between  the  sclera  and  the  ciliary  body,  with  its  plane  parallel 
to  both  (Fig.  108).  If  all  the  fibers  of  the  sclera  have  been  divided, 
this  can  be  done  without  any  resistance.  Soon  the  point  of  the  spatula 


FIG.  109.  FIG.  no. 

Figs.  109  and  no  show  the  position  of  the  spatula  during  the  performance  of  the 
lateral  movement  intended  to  detach  the  ciliary  body. 


appears  below  in  the  angle  of  the  chamber.  Now  the  spatula  is  pushed 
forward  with  lateral  movements  to  the  right  and  to  the  left  (Figs. 
109  and  no)  and  in  this  manner  the  ciliary  body  is  detached  from  the 
sclera.  The  aqueous  humor  does  not  escape  during  this  procedure, 
unless  one  edge  of  the  spatula  is  turned  forward  slightly,  causing  the 
wound  to  gape.  If  the  ciliary  body  is  not  hurt  during  the  incision, 
no  bleeding  occurs  into  the  anterior  chamber. 

At  the  beginning  of  the  operation  we  must  be  careful  not  to  injure 
the  anterior  ciliary  veins,  which  are  often  dilated  in  glaucomatous 
eyes,  as  such  a  hemorrhage  would  not  only  make  the  further  progress 
of  the  operation  difficult,  but  also  during  the  introduction  of  the  spatula 
cause  blood  to  be  sucked  into  the  anterior  chamber.  Bleeding  from 
the  small  scleral  vessels  is  best  prevented  by  repeated  dropping  of 
adrenalin  into  the  wound  during  the  incision.  One  may  even  be 
compelled  to  stop  severe  hemorrhage  from  a  ciliary  vein,  injured  at  its 
point  of  exit  from  the  sclera,  by  application  of  the  thermocautery. 
If  the  cut  is  carried  too  deep,  the  vitreous  may  be  pushed  into  the  wound 


202  OPHTHALMIC    SURGERY. 

after  division  of  the  uvea.  The  spatula  must  be  introduced  carefully 
and  pushed  forward  close  to  the  posterior  surface  of  the  sclera,  in 
order  not  to  get  behind  the  iris.  By  the  entrance  of  the  spatula  into 
the  anterior  chamber  the  ligamentum  pectinatum  is  divided,  the 
angle  of  the  chamber  opened,  and  the  ciliary  body,  together  with  the 
iris  springing  from  it,  is  detached  from  the  sclera. 

An  iridodialysis  is  no  more  to  be  feared  than  an  injury  to  the  canal 
of  Schlemm,  as  the  iris  arises  from  the  anterior  surface  of  the  ciliary 
body,  and  the  latter  is  sufficiently  protected  through  a  projection  of 
the  sclera.  Occasionally,  the  detachment  of  the  ciliary  body  from  the 
sclera  may  be  plainly  distinguished  by  the  recess  of  the  chamber 
becoming  black  just  as  in  iridodialysis.  After  withdrawal  of  the 
spatula  the  ciliary  body  resumes  its  original  position  and  the  angles  of  the 
chambers  show  no  further  visible  alteration.  If,  during  the  operation, 
a  hemorrhage  into  the  anterior  chamber  occurs,  a  pressure-dressing 
must  at  once  be  applied.  This  not  only  prevents  a  further  accumu- 
lation of  blood,  but  also  causes  a  disappearance  of  part  of  the  blood 
already  present  in  the  eye. 

One  of  the  most  frequent  complications  is  the  detachment  of 
Descemet's  membrane  from  the  cornea.  If  the  spatula  is  not  sharp 
enough  to  sever  the  fibres  of  the  ligamentum  pectinatum,  it  may  glide 
in  front  of  them  on  the  anterior  side  of  Descemet's  membrane,  thus 
getting  caught  between  the  latter  and  the  parenchyma  of  the  cornea. 
This  faculty  position  of  the  instrument  is  recognized  by  a  marked 
resistance.  By  slightly  withdrawing,  the  spatula  must  be  freed  before 
the  undermining  is  performed,  otherwise  the  membrane  becomes 
detached,  thus  leading  to  an  opacity  of  the  corneal  parenchyma, 
which,  however,  disappears  within  a  few  weeks.  Generally  the  spatula 
finds  its  right  way  even  in  those  eyes  in  which  the  root  of  the  iris  is 
attached  to  the  posterior  surface  of  the  cornea  (peripheral  anterior 
synechia),  and  an  iridodialysis  is  an  exceptional  occurrence. 

After  withdrawing  the  spatula  from  the  wound  the  conjunctiva 
is  sutured  and  the  eye  bandaged. 

The  operation  is  undoubtedly  much  less  radical  and  associated  \vith 
much  less  danger  for  the  eye  than  an  iridectomy.  To  test  its  influence, 
I  purposely  did  not  permit  the  aqueous  humor  to  escape  from  the  eye 
in  most  of  my  cases,  so  that  immediately  after  the  operation  the  eye 
was  as  hard  as  before.  In  this  manner,  therefore,  I  could  observe 
the  effects  of  the  operation  with  the  factor  of  puncture  omitted  from 


GLAUCOMA.  203 

consideration.  I  do  not  mean,  however,  that  one  should  not  let  out 
the  aqueous  humor,  as  it  may  be  irremissible  to  reduce  the  tension  at 
once.  Neither  do  I  use  miotics  after  the  operation,  although  we  think 
their  employment  is  a  great  advantage,  because  the  consequent  con- 
traction of  the  pupil  aids  in  pulling  the  freed  root  of  the  iris  away  from 
the  angle  of  the  anterior  chamber. 

The  proper  results  of  cyclodialysis  develop  gradually  and  attain 
their  highest  degree  only  one  to  three  days  later.  According  to  the 
condition  of  the  eye  after  the~  operation,  three  kinds  of  cases  may  be 
distinguished:  Those  in  which  (i)  the  tension  is  reduced  perma- 
nently; (2)  the  diminution  of  the  pressure  is  only  temporary;  (3)  the 
operation  had  no  influence  at  all.  In  the  first  class  of  cases  (about 
30  per  cent.)  the  tension  sinks  gradually  during  the  first  three  days 
after  the  operation,  and  the  eye  may  even  become  softer  than  normal. 
The  previously  hazy  cornea  becomes  lustrous,  the  anterior  chamber 
somewhat  deeper,  though  it  remains  shallower  than  normal,  the  pupil 
a  little  less  dilated  than  before.  In  this  condition  the  eye  may 
remain  permanently.  In  about  40  per  cent,  the  diminution  of  the 
tension  is  only  temporary  and  the  increase  of  pressure  returns  within 
a  fewr  weeks;  and  in  about  30  per  cent,  the  operation  had  no  effect 
at  all  on  the  glaucoma.  This  is  the  result  especially  in  glaucoma 
absolutum. 

Cyclodialysis  is  indicated  in,  i.  Cases  of  primary  glaucoma, 
in  which  the  iridectomy  is  not  only  difficult  but  dangerous,  either 
because  of  the  increase  in  pressure  being  very  high,  or  the  intra-ocular 
changes  so  far  advanced,  that  a  regular  iridectomy  is  practically 
impossible  (no  anterior  chamber,  atrophic  iris,  maximal  dilatation  of 
the  pupil).  The  performance  of  the  cyclodialysis  is  independent  of 
the  existence  of  the  anterior  chamber,  and  complications  mentioned  in 
iridectomy  may  be  disregarded. 

Even  though  the  reduction  of  pressure  may  be  only  a  temporary 
one,  the  operation  has  to  be  considered  as  a  valuable  preliminary 
to  iridectomy.  If  the  tension  is  once  diminished  by  the  cyclodialysis, 
an  iridectomy  can  be  accomplished  without  any  of  the  dangers  already 
described. 

2.  In  cases  of  glaucoma  in  patients  who  have  lost  the  other  eye  by 
glaucoma  malignum  or  a  severe  hemorrhage  after  an  iridectomy,  also 
in  old,  infirm,  coughing  or  restless  people,  because  after  this  operation 
such  patients  do  not  need  to  be  kept  in  bed. 


204  OPHTHALMIC   SURGERY. 

3.  The  operation  renders  remarkable  services  in  certain  cases  of 
secondary  glaucoma  caused :  (a)  By  anterior  synechia,  in  which  in  spite 
of  iridectomy  the  tension  increases  again,  (b)  By  luxation  of  the  lens 
in  the  vitreous  chamber.  Loss  of  vitreous,  unavoidable  in  performing 
an  iridectomy  and  rendering  the  same  dangerous  and  its  result  uncer- 
tain, does  not  complicate  the  cyclodialysis.  (c)  After  cataract-extrac- 
tion, provided  that  the  edges  of  the  coloboma  are  in  their  proper 
position.  If  there  is  adhesion  of  one  or  both  sides  of  the  coloboma  to 
the  operation-scar,  the  excision  of  the  attached  iris  is,  of  course,  indi- 
cated (page  190). 

In  brief,  cyclodialysis,  though  able  to  diminish  the  intra-ocular 
pressure,  cannot  be  called  preferable  or  even  equal  to  the  iridectomy. 
It  should  not  be  used  indiscriminately  in  place  of  iridectomy,  but 
should  be  considered  as  a  valuable  aid  when  iridectomy  fails  or  is 
contra-indicated. 

The  suggestion  of  this  operation  by  Heine  had  its  origin  in  the 
articles  by  Fuchs  giving  detailed  descriptions  of  the  chorioidal  detach- 
ment following  iridectomy  for  glaucoma  and  extraction  of  cataract, 
pointing  out  the  co-existent  diminution  of  pressure,  and  presuming 
that  the  chorioidal  detachment  was  brought  about  by  the  aqueous 
humor  oozing  backward  through  tears  in  the  ligamentum  pectinatum 
produced  by  the  operation.  Heine  tried,  by  establishing  through  an 
artificial  cleft  in  the  ligament  a  communication  between  the  anterior 
chamber  and  the  suprachorioidal  space,  to  give  rise  to  a  detachment 
of  the  chorioid  and  thereby  to  a  reduction  of  the  intra-ocular  pressure. 
In  conceiving  the  method  of  the  cyclodialysis  he  took  for  granted,  first, 
that  the  tear  would  not  heal  again  spontaneously,  and,  second,  that  the 
suprachorioidal  space  represented  either  a  natural  passage  for  the 
intra-ocular  circulation  respectively  for  the  carrying  off  of  the  liquids 
from  the  interior  of  the  eye,  or  that  it  was  created  such  a  one  by  the 
operation.  But  the  expected  detachment  of  the  chorioid  failed  to 
appear,  even  when  the  eyes  had  been  perfectly  soft.  The  fact  that  in 
successful  cases  the  tension  remains  below  normal  for  months  proves 
that  the  result  is  independent  of  a  supposed  detachment  of  the  chorioid, 
which,  as  a  rule,  pvasses  away  within  a  few  days  or,  if  extensive,  within  a 
few  weeks,  and  with  it  the  lowering  of  the  tension.  The  theory, 
therefore,  on  which  the  operation  had  been  based,  seems  to  be  incorrect. 
But  this  should  not  bias  our  actual  judgment.  It  is  likely  that  the 
occasional  success  is  accomplished  by  the  undermining  of  the  angle 


GLAUCOMA.  205 

of  the  anterior  chamber.  Cyclodialysis  should  be  regarded  as  an 
operation  to  free  this  angle,  just  as  many  other  methods  that  have 
been  recommended  for  glaucoma,  to  which  iridectomy  also  probably 
belongs. 

OPERATIONS  FOR  SECONDARY  GLAUCOMA. 

The  indications  for  operation  in  secondary  glaucoma  are  dependent 
upon  whether  the  phenomena  are  only  temporary  or  whether  the 
increase  of  pressure  will  remain  permanent. 

Paracentesis  of  the  cornea  is  indicated  in  transient  increase  of 
pressure;  as,  for  example,  in  traumatic  cataract  with  rapid  swelling 
of  the  lens;  and  in  acute  iritis,  in  which  the  increase  in  pressure  is 
associated  with  the  anterior  chamber  deeper  than  in  the  normal  eye. 
However,  the  operation  should  not  be  done  until  after  the  usual  local 
applications  of  ice-compresses  and  atropin  have  failed,  especially  in 
cases  of  iritis. 

The  incision  is  made  with  the  lancet  at  the  limbus  below  and  not 
more  than  3  mm.  long.  The  cocainized  eye  is  fixed  laterally.  The 
site  of  fixation  is  not  so  important  as  an  iridectomy  is  not  contem- 
plated, and  the  incision  need  not  be  made  exactly  in  the  vertical 
meridian.  The  lancet,  held  in  the  right  hand,  is  applied  almost 
vertically  against  the  limbus,  and  penetrates  the  cornea.  The  length 
of  the  cut,  however,  must  not  exceed  3  mm.  As  soon  as  the  point 
appears  in  the  anterior  chamber,  its  direction  must  be  changed  to  that 
of  the  plane  of  the  iris,  as  in  operations  previously  described.  All 
backward  movements  of  the  lancet  should  be  avoided,  in  order  to  - 
prevent  a  disastrous  escape  of  the  aqueous  humor. 

When  the  lancet  is  now  withdrawn,  the  wound-edges  come  together 
so  that  the  aqueous  cannot  flow  off.  The  operator  may  permit  it  to 
run  out  as  slowly  as  he  desires  and  in  any  quantity  he  pleases,  by 
slightly  depressing  the  scleral  wound-margin  with  the  spatula,  thus 
making  the  wound  a  little  gaping.  Sudden  escape  of  the  aqueous 
humor  is  not  only  painful,  but  may  cause  prolapse  of  the  iris  and 
hemorrhage  from  the  iris,  and  even  in  the  retina  as  a  result  of  the 
sudden  diminution  of  pressure.  A  lancet  with  stop-shoulders  has  been 
devised  which  will  prevent  an  over-penetration  into  the  eye,  but  such 
instruments  are  superfluous  for  the  operator  of  experience.  No 
force  must  ever  be  employed  when  introducing  the  lancet.  If  the 
point  is  bad,  it  is  preferable  to  use  another  instrument.  A  faultless 


206  OPHTHALMIC    SURGERY. 

knife-point  penetrates  the  cornea  without  any  appreciable  resistance. 
If  the  pressure  is  greatly  increased,  it  is  our  custom  not  to  permit  all 
the  aqueous  humor  to  escape,  but  only  just  as  much  as  to  reduce  the 
pressure  to  normal  or  a  trifle  below.  Thus  we  are  most  likely  to  pre- 
clude disastrous  intra-ocular  hemorrhages.  If  the  iris  is  floated  out 
during  the  sudden  escape  of  the  aqueous  humor,  it  should  be  at  once 
accurately  replaced  with  a  spatula.  Only  in  exceptional  cases,  when 
the  protrusion  of  the  iris  is  several  times  repeated,  is  excision  of  a 
small  piece  indicated.  This  unpleasant  accident  occurs  when  the 
incision  has  been  made  too  long. 

Puncture  of  the  cornea  may  be  repeated  as  often  as  needed.  If, 
for  example,  in  acute  iritis  the  tension  increases  the  next  day,  the 
scleral  lip  of  the  wound  after  cocainizing  may  be  slightly  depressed 
with  the  spatula  and  the  aqueous  humor  allowed  to  again  escape. 
The  healing  of  the  wound  does  not  advance  so  quickly  for  several  days 
as  to  hinder  easy  re-opening  by  passing  the  spatula  carefully  between 
the  edges. 

If  the  corneal  puncture  is  made  because  of  increase  in  pressure, 
the  result  of  swelling  of  the  lens,  it  is  better  to  make  the  cut  somewhat 
longer  (5  mm.),  so  as  to  permit  not  only  the  aqueous  humor  to  escape, 
but  also  extract  some  of  the  lens-mass  itself  by  massage,  as  described 
elsewhere.  In  such  a  case  the  operation  more  nearly  resembles  a 
linear  extraction. 

Puncture  of  the  cornea  may  also  be  employed  in  progressive 
corneal  ulcers,  and  is  then  frequently  combined  with  cauterization 
of  the  ulcer.  The  puncture  may  be  advantageous  in  those  cases  in 
which  a  rupture  is  imminent.  The  obliteration  of  the  anterior  chamber 
by  the  puncture  overcomes  all  the  disadvantages  of  a  sudden  rupture 
of  the  ulcer,  such  as  prolapse  of  the  iris,  etc.  In  chronic  inflammation 
of  the  cornea  (keratitis  profunda)  puncture  occasionally  exerts  a 
favorable  influence  on  the  disease-process. 

Secondary  glaucoma,  in  which  the  increase  of  pressure  is  certainly 
not  of  transient  nature,  requires  a  typical  iridectomy,  as  described  in 
the  chapter  on  primary  glaucoma.  This  is  true,  therefore,  in  increase 
of  pressure  due  to  adhesion  of  the  iris  to  the  cornea  or  to  change  of 
position  of  the  lens,  and  other  conditions,  as  previously  mentioned. 

The  performance  of  the  iridectomy  in  secondary  glaucoma 
may  be  difficult  because  of  the  accompanying  pathological  changes 
in  the  eye.  For  instance,  the  iris  may  be  so  atrophic  from  the  chronic 


GLAUCOMA.  20- 

inflammation  tluu  it  cannot  be  pulled  forward  with  the  forceps,  as  it 
tears  at  the  slightest  touch,  and  we  must  be  satisfied  with  tearing  out 
single  pieces  with  the  forceps  instead  of  excising  one  section.  Again, 
the  iris  may  have  grown  fast  to  the  lens-capsule,  and  we  may  succeed 
in  drawing  it  forward  and  in  excising  a  portion,  but  the  pigment-layer 
remains  adherent  to  the  lens-capsule,  rendering  valueless  the  optical 
effect  of  the  operation. 

In  luxation  of  the  lens  or  ectasia  of  the  sclera  it  is  prolapse  of 
the  vitreous  which  produces  severe  complications  during  the  opera- 
tion. \Ye  should  never  operate  in  a  case  of  luxation  or  subluxation  of 
the  lens  (except  luxation  in  the  anterior  chamber)  unless  forced  to  by 
an  increase  of  pressure.  Experience  has  shown  that  some  eyes  tolerate 
a  displacement  of  the  lens  without  a  corresponding  increase  of  pressure, 
at  least  for  some  time.  Operative  procedures  in  these  cases  are  always 
so  dangerous  that  they  should  be  postponed  until  the  last  resort.  As 
the  zonula  is  torn,  the  vitreous  presents  in  the  wound  as  soon  as  the 
incision  is  made.  If  the  iris  is  floated  forward,  it  may  be  easily  grasped 
and  excised.  If,  however,  the  vitreous  pushes  the  iris  backward,  all 
attempts  to  bring  it  forward  with  the  forceps  would  terminate  in 
failures  and  should,  therefore,  be  abandoned.  Occasionally  we  may 
be  able  to  catch  the  iris  with  a  blunt  hook  and  to  draw  it  forward. 
Should  that  also  fail,  one  has  to  desist  from  excising  a  piece  of  the  iris. 
If  afterward  the  operative  wound  becomes  ectatic  and  the  eye  con- 
stantly painful  because  of  the  increased  pressure,  and  vision  is  ulti- 
mately lost,  nothing  remains  to  be  done  except  to  enucleate  the  eye. 

If  the  lens  is  displaced  into  the  anterior  chamber  an  operation 
for  its  removal  must  be  immediately  undertaken,  as  experience  has 
shown  that  in  such  cases  increase  in  intra-ocular  tension  quickly  follows. 
In  order  to  prevent  a  slipping  of  the  lens  backward  into  the  vitreous 
chamber,  the  pupil  is  first  contracted  with  eserin.  Then  the  anterior 
chamber  is  opened  by  an  incision  with  (iraefe's  knite  at  the  lower 
limbus  and  the  lens  brought  forward  with  the  loop.  As  the  vitreous 
and  anterior  chamber  openly  communicate,  the  appearance  of  the 
vitreous  in  the  wound  is  the  rule  in  spite  of  precautions. 

If  a  cyst  of  the  iris  has  led  to  increase  of  pressure  we  must  not  be 
satisfied  with  an  iridectomy  alone,  but  endeavor  to  extirpate  the 
entire  cyst  by  suitable  incision. 

The  operation  for  increase  of  pressure  in  seclusion  of  the  pupil, 
when  the  iris  has  been  pushed  forward  in  the  form  of  a  hum]),  deserves 


208 


OPHTHALMIC    SURGERY. 


special  mention.  A  formal  iridectomy  is  hardly  possible  as  the  root 
of  the  iris  is  often  applied  extensively  against  the  posterior  wall  of  the 
cornea.  The  operation  adapted  for  such  cases  is  transfixion.  This 
is  done  with  a  Graefe  knife,  which  is  pushed  into  the  anterior  chamber 
through  the  cornea  i  mm.  to  the  inner  side  of  the  temporal  border 
of  the  cornea  and  a  counter-puncture  made  at  a  symmetrical  point. 
The  knife  is  then  pulled  out.  The  points  of  entrance  and  exit  lie  in 
the  horizontal  meridian  of  the  cornea,  and  the^blade  of  the  knife,  held 


FIG.  in. 


FIG.  112. 
FIGS,  in  and  112.     Transfixion  in  seclusion  of  the  pupil. 

parallel  to  the  base  of  the  cornea,  penetrates  through  the  projecting  iris 
and  produces  in  it  several  openings  (Figs,  in  and  112),  through  which 
a  new  communication  is  established  between  the  anterior  and  posterior 
chambers.  In  most  cases  the  iris  assumes  its  normal  position  almost 
at  once  and  the  intra-ocular  pressure  becomes  normal.  If  no  new 
inflammation  of  the  iris  follows,  a  permanent  result  may  be  expected. 
If,  however,  there  is  a  new  outbreak  of  iritis,  which  would  cause  a 
closure  of  the  openings  through  a  formation  of  an  exudate,  it  is  better 
to  proceed  to  establish  a  normally  deep  chamber  and  then  to  perform  a 
regular  iridectomy,  in  order  to  prevent  a  recurrence  of  the  increase  in 
pressure. 


CHAPTKR   XVII 
PROLAPSE  OF  THE  IRIS.     CONJUNCTIVOPLASTY. 

Every  Prolapse  of  the  Iris  should  be  Excised.  -Attempts  at  re-posi- 
tion of  a  prolapsed  iris  should  be  avoided,  not  only  on  account  of  the 
danger  of  intraocular  infection,  but  also  because  of  the  uselessness  of 
such  a  procedure.  The  replaced  iris  will  again  prolapse.  It  is.  there- 
tore,  best  to  excise  not  only  an  iris  that  has  protruded  through  the  open- 
ing ot  a  perforated  ulcer  or  through  a  wound  due  to  injury,  but  also 
a  prolapsed  iris  following  an  extraction  without  iridectomy. 

The  Operation. — Xot  only  should  that  portion  protruding  from 
the  opening  be  cut  off.  but  the  iri.s  should  be  completely  freed  from 
its  connection  with  the  wound,  in  order  to  avoid  the  formation  of  an 
anterior  synechia.  with  its  consequent  sequehe.  As  the  prolapsed  iris 
rapidly  becomes  covered  with  fibrinous  exudation,  making  its  borders 
indefinable,  this  exudate  must  first  be  pulled  off  with  a  forceps,  after 
which  the  black  point  or  swelling  of  the  prolapse  makes  its  appearance. 
By  means  of  a  conical  sound  the  prolapse  is  then  freed  from  the  edges 
of  the  wound  in  all  directions.  In  doing  this  it  is  necessary  to  avoid 
wounding  the  capsule  of  the  lens,  which,  by  obliteration  of  the  anterior 
chamber,  is  brought  to  lie  close  to  the  posterior  surface  of  the  cornea. 
The  sound  is  carefully  pushed  around  the  whole  periphery  of  the  open- 
ing between  the  prolapse  and  the  posterior  surface  of  the  cornea,  so 
that  the  iris  is  loosened  on  all  sides.  During  this  attempt  the  aqueous 
humor  is  continually  escaping.  The  prolapsed  iris  is  then  seized  with 
the  iris-forceps  close  to  the  opening,  drawn  out  a  little,  and  cut  off 
with  the  de  Wecker's  scissors  close  u>  tile  edge  of  the  wound.  As  tin- 
iris  usually  retains  its  power  of  retraction,  immediately  after  the  exci- 
sion, it  withdraws  itself  into  the  anterior  chamber,  and  produces  a 
well-situated  coloboma  in  place  of  the-  previous  prolapse. 

If  the  edges  of  the  coloboma  do  not  lie  in  a  proper  position,  and  the  si/.e 
of  the  opening  permits,  it  is  advisable  to  introduce  a  spatula  and  replace 
the  iris.  As  this  may  be  impossible  with  a  small  opening,  care  should 
be  taken  to  draw  out  and  excise  enough  of  the  iri-  to  allow  it  to  spon- 
taneously withdraw  to  a  sufficient  extent.  If.  however,  1  he  latter  does 
not  occur,  an  attempt  must  be-  made  to  introduce  a  blunt  tenaculum 

14  2O() 


210  OPHTHALMIC    SURGERY. 

into  the  anterior  chamber,  and,  withdrawing  it  out  of  the  wound 
between  the  iris  and  the  posterior  corneal  wall,  pull  out  the  iris  caught 
in  the  hook,  so  that  a  proper  excision  can  be  done.  After  the  operation 
is  completed  a  drop  of  atropin  is  instilled  in  the  eye  to  retract  the  iris 
as  far  as  possible  and  avoid  its  adhesion  to  the  edges  of  the  wound. 
The  fact  that  the  prolapse  has  occurred  through  perforation  of  an 
ulcer  is  not  a  contraindication  to  its  immediate  excision,  notwithstand- 
ing the  claim  that  there  is  great  possibility  of  an  infection  of  the  interior 
of  the  eye  through  replacement  of  the  borders  of  the  coloboma.  If  the 
tendency  to  infection  should  exist,  the  prolapse  would  afford  the  best 
channel  by  which  the  microorganisms  could  gain  entrance  to  the  eye. 

Excision  of  a  prolapse  of  the  iris  may  occasionally  be  difficult  and 
it  is  necessary  to  cocainize  thoroughly  the  conjunctival  sac  by  instilla- 
tion of  a  3  per  cent,  solution.  As  the  eyes  are  usually  much  irritated 
and  injected,  adrenalin  should  be  used  simultaneously,  as  the  cocain 
develops  its  greatest  effect  after  contraction  of  the  blood-vessels.  Not- 
withstanding thorough  cocainization,  the  iris  often  remains  extremely 
sensitive,  and  in  spite  of  fixation  of  the  eyeball  with  forceps,  especially 
at  that  moment  when  the  iris  is  drawn  out  and  excised,  an  abrupt 
movement  of  the  patient  may  give  rise  to  severe  injury  of  the  iris 
(iridodialysisj.  In  children  the  operation  should  always  be  done 
under  general  anesthesia.  This  should  also  be  the  rule  in  restless  and 
timorous  adults. 

A  second  danger  is  the  possibility  of  a  wound  of  the  capsule  of  the 
lens.  This  can  be  readily  avoided  if  the  operator  takes  sufficient 
precautions  in  introducing  the  blunt  tenaculum  for  the  purpose  of 
replacing  the  iris.  However,  this  accident  may  be  caused  by  restless- 
ness on  the  part  of  the  patient  during  the  undermining  of  the  prolapse 
with  the  pointed  conical  sound.  If  cocain  is  dropped  directly  on 
the  prolapsed  iris  after  it  is  uncovered,  its  sensitiveness  is  greatly 
diminished. 

The  wound  in  the  cornea  which  remains  after  excision  of  the  pro- 
lapse, usually  closes  rapidly;  frequently  the  anterior  chamber  is  re- 
established on  the  day  after  the  operation.  The  smaller  the  opening, 
the  more  readily  and  surely  does  the  wound  close.  The  conditions 
for  healing  are  less  favorable  in  large  perforations.  It  is  our  established 
rule  not  to  excise  a  prolapse  of  the  iris  if  the  opening  amounts 
to  one-fourth  the  diameter  of  the  cornea.  Naturally,  this  can 
not  be  readily  determined  in  advance.  A  large  prolapse  sometimes 


PROLAPSE    OF    THE    IRIS.  211 

comes  out  through  a  small  opening  and,  with  mushroom-like  swelling, 
overlaps  the  borders  of  the  corneal  wound.  If  the  patient  has  been 
seen  before  the  prolapse  occurred,  the  operator  will  not  be  thus  deceived, 
but  it  may  happen  that  the  real  conditions  are  revealed  only  at  the 
time  of  operation  upon  attempting  to  undermine  the  prolapse. 
When,  for  example,  one-fourth  or  more  of  the  cornea  has  been  lost  by 
ulceration,  the  excision  of  the  iris  brings  the  lens-capsule  to  lie  in  the 
wound  throughout  its  extent.  As  the  scar-formation  is  not  as  rapid 
in  the  cornea  as  it  is  in  other  tissues,  the  wound  may  remain  open  for 
some  time,  and  during  this  period  the  eye  is  constantly  exposed  to  the 
danger  of  infection.  If  the  exposed  lens-capsule  cannot  withstand  the 
intra-ocular  pressure,  it  finally  protrudes  and  ruptures,  the  lens-sub- 
stance first  appears  in  the  opening  and  later  the  hyaloid  membrane 
bursts,  allowing  the  vitreous  humor  to  prolapse.  These  sequelae 
are  to  be  feared  only  in  large  prolapses,  such  as  occur  in  destruction  of 
the  cornea  by  acute  blennorrhea  or  serpiginous  ulcer.  But  even  with 
the  medium-sized  openings,  the  operator  has  to  be  satisfied  if  a  flat 
cicatrization  results  with  fusion  of  the  lens-capsule  and  partial  or  total 
clouding  of  the  lens.  Frequently  these  cases  end  with  a  slowly  devel- 
oping atrophy  of  the  eyeball.  Therefore,  it  is  best  not  to  excise  the 
prolapse,  which  let  alone  will  form  the  natural  means  of  closing  the 
large  wound.  The  endeavor  should  be  rather  to  produce  merely  a 
flat  cicatrix.  Therefore,  the  intra-ocular  pressure  should  be  carefully 
controlled,  and  if  it  rises,  an  immediate  iridectomy  done. 

In  extensive  synechia  an  iridectomy  should  be  performed  before 
the  patient  leaves  the  hospital,  in  order  to  avoid  the  danger  of  increase 
in  pressure  and  development  of  a  staphyloma.  The  continuous  appli- 
cation of  a  pressure-bandage  is  advisable  to  produce  a  flat  cicatrix. 
A  typical  picture  is  seen  in  those  patients  who  have  suffered  from  a  well 
advanced  serpiginous  ulcer.  An  extensive  synechia  of  the  iris  has 
been  produced,  either  spontaneously  or  after  Saemisch's  incision,  writh 
a  peripheral  part  of  the  cornea  still  transparent.  At  first  the  tension 
is  reduced,  but  finally  becomes  normal.  At  the  seat  of  the  prolapse 
there  is  formed  a  flat  scar.  Suddenly  the  pressure  increases,  usually 
with  violent  pains,  and  immediately  the  still  soft  cicatrix,  which  is 
often  the  seat  of  hemorrhages,  protrudes  in  the  form  of  a  hump. 
Under  such  circumstances  the  performance  of  iridectomy  is  difficult, 
as  the  anterior  chamber  is  usually  obliterated,  the  iris  atrophic,  and 
the  eye  painful.  This  almost  invariable  result  can  be  avoided  if  a 


212  OPHTHALMIC   SURGERY. 

broad  iridcctomy  is  executed  in  the  unaffected  portion  of  the  cornea 
as  soon  as  an  anterior  chamber  has  been  established  during  the  course 
of  cicatrization  of  the  prolapse  and  before  tension  rises. 

Conjunctivoplasty  is  a  significant  advance  in  the  treatment  of 
large  prolapses  of  the  iris  which  is  advocated  especially  by  Kuhnt. 
By  this  means  it  is  possible  to  excise  even  a  large  prolapse,  to  protect 
the  eye  from  extensive  synechia  and  at  the  same  time  close  the  defect 
by  solid  tissue. 

The  operation  is  as  follows:     After  excision  of  the  prolapsed  iris, 
a  cleaned  ulcer  with  the  perforation  lies  exposed.     Either  the  edges  of 
the  defect  are  flat  and  offer  a  larger  surface  for 
adhesion  to  the  conjunctival  flap,   in  which   case 
the  edges  should  be  scraped  with  a  sharp  curette, 
to    remove   the    epithelium   that   has   grown    over 
them,  or  they  are  perpendicular,  in  which  case  the 
FIG.    113.  — Con-     chances    for   fusion  with  the  flap  are  less  favor- 

junctivoplasty.    Dia-         ,  .            .                                          ,       .  ,1111 
gram     showing    ap-  able.      A    flap    IS   now  made   from  the   bulbar   COn- 
pear  a  nee  s  after  iunctiva  by  first  detaching  with  the   scissors   the 

excision  of    the  pro-  J  _    J 

lapsed  part  of  the  iris,     conjunctiva    at    the  limbus  corresponding  to   the 

The  ulcer  in  the  lower         ,  ,  •  i  111^^1^ 

half  of  the  cornea  is  ulcer,  making  a  second  cut  parallel  to  the  first 
free  from  the  iris,  at  a  distance  almost  twice  as  great  as  the  width 

\vhich  shows  the  ordi-  .  .  . 

nary  coioboma.    To     of  the  ulcer,  and  uniting  the  two  by  a  curved  inci- 

SJSJftaESU  sion  <Fig-  ,II3)-  The  flap  formed'in  this  manner 

of  the  bulbar  con-  is  undermined,  and  its  base  removed  far  enough 
back  to  render  it  freely  movable.  If  the  ulcer 
is  at  the  edge  of  the  cornea,  the  flap  may  arise  from  the  border- 
ing limbus;  but  if  the  loss  of  substance  is  central,  it  may  be  covered 
either  by  a  flap  brought  horizontally  over  the  cornea  or  by  one 
drawn  vertically  over  it.  In  the  former  case  the  detachment  of  the 
conjunctiva  must  be  performed  above  or  below,  and  the  base  of  the 
flap  must  lie  externally  or  internally.  The  latter  method  is,  therefore, 
to  be  preferred  on  account  of  the  abundance  of  conjunctiva  in  the 
superior  fold,  which  readily  permits  the  formation  of  a  flap,  while  inter- 
nally and  externally  there  is  little  conjunctiva  to  spare.  The  only 
objection  is  the  possible  danger  of  limiting  the  movements  of  the 
eyeball  by  shortening  the  conjunctival  fold  to  too  great  an  extent. 

After  the  flap  has  been  rotated  to  the  correct  position,  so  that  it  well 
covers  the  loss  of  substance,  its  apex  is  fastened  by  a  few  fine  silk-sutures 
to  the  bulbar  conjunctiva  on  the  side  opposite  to  that  on  which  the  base 


PROI.APSK     01      Till;     IRIS.  21  ^ 

of  the  flap  is  attached  iFig.  114).  As  the  conjunctiva  often  shows  a 
tendency  to  curl,  one  or  more  sutures  may  be  introduced  through  the 
lateral  edges  of  the  flap,  in  order  to  keep  it  well  stretched.  Naturally, 
too  much  dependence  cannot  be  placed  upon  these  sutures,  as  they 
frequently  cut  through  as  early  as  the  following  day.  Still,  even  this 
short  period  usually  suffices  to  maintain  the  flap  in  its  correct  position. 
The  wound  in  the  bulbar  conjunctiva  left  by  excision  of  the  flap  may 
be  permitted  to  heal  by  itself,  especially  if  there  is  difficult}-  in  covering 
it  by  drawing  upon  the  surrounding  membrane; 
or  an  attempt  may  be  made  to  at  least  partly  ~"\ 

draw   the    conjunctiva  over  the  defect   with   the 
aid  of  incisions  to  relieve  tension. 

After  the  operation  both  eyes  are  bandaged 

to  insure  a  proper  position  of  the  flap  by  exclud-          i'^'-    114-     i>ia«ram 

,  .,  .,.  .  ..     .  showing  the  conjunctiva! 

ing  the  possibility  ot  ocular  movements.     Ik-tore      tia]1    turned    over    the 

applving  the  dressings,  the  operator  should  assure      u.Kr.r<  nand  an'uhi:(1   1" 

the  bulbar  conjunctiva  in 


himscli    that  the   flap  does  not  shift  its  position      such   manner"  that    the 

ulcer        i 
covered. 


during    the    upward    rotation    that    accompanie 


closure  of  the  eyelids,  and,  if  necessary,  introduce 

an  additional  suture  to  prevent  this  displacement.  The  bandage  should 
be  changed  on  the  following  day,  as  we  have  to  deal  frequently  with 
excessive  conjunctiva!  and  lachrymal  secretion.  Both  eyes  are  kept 
closed  for  at  least  three  days.  At  first  the  llap  appears  quite  swollen, 
and  some  time  may  elapse  before  it  again  assumes  the  condition  of 
normal  conjunctiva.  It  is  generally  not  necessary  to  remove  the  stitches, 
as  they  drop  out  of  themselves  in  a  few  days.  If  the  loss  of  substance 
has  occurred  in  the  middle  of  the  cornea,  the  separation  of  the  flap  from 
its  base  can  be  tmdertaken  when  the  eye  lias  become  completely  free 
from  congestion  and  the  process  of  healing  is  at  an  end.  The  results 
of  this  operation  are  in  many  cases  remarkable,  but  occasionally,  in 
spite  of  closure  of  the  ulceration,  an  atrophy  of  the  eyeball  finally  sets 
in.  Of  course  the  method  cannot  be  blamed  for  these  bad  results,  as 
they  are  caused  by  severity  of  the  primary  changes. 

Conjunctivoplasty  is  not  limited  to  perforating  ulcers,  but  is  valuable 
in  losses  of  substance  from  other  causes,  especially  to  gaping  wounds 
following  injury. 

In  transplantation  of  the  cornea,  a  conjunctiva!  flap  properly 
applied  over  the  cornea  will  retain  the  transplanted  piece  in  its  position 
during  the  first  few  davs.  \Yhen  tin-  piece'  has  become  attached  with 


214  OPHTHALMIC    SURGERY. 

sufficient  firmness,  the  conjunctival  flap  may  be  returned  to  its  original 
position  or  may  be  excised. 

De  Wecker's  method  of  transplantation  is  of  great  value  in  severe 
injuries.  It  consists  in  undermining  the  conjunctiva  on  all  sides  from 
the  limbus  to  the  insertions  of  the  recti  muscles,  after  which  this  mov- 
able conjunctiva  is  drawn  completely  over  the  cornea  and  closed  in 
purse-string  fashion  by  several  sutures.  The  raw  surface  of  the  con- 
junctiva closes  the  defect  and  fuses  with  the  edges  of  the  wound.  After 
completion  of  the  cicatricial  process,  the  conjunctiva  may  again  be 
detached,  after  which  it  returns  to  its  normal  position  in  all  directions, 
with  the  exception  of  the  point  of  fusion.  A  total  detachment  of  the 
conjunctiva  at  the  limbus  is  not  always  necessary;  a  partial  detachment 
may  suffice  to  draw  the  conjunctiva  over  the  cornea  and  attach  it  to 
the  opposite  limbus. 

The  cases  thus  far  discussed  refer  to  prolapse  of  the  iris  through  a 
wound  of  the  cornea  or  at  the  limbus.  There  remains  to  be  considered 
the  method  of  procedure  in  wounds  of  the  sclera  with  prolapse  of 
portions  of  the  ciliary  body  or  chorioid.  If  the  injury  is  not  too 
severe,  so  that  there  is  hope  of  preserving  the  eye,  the  same  rule  is  to 
be  observed  as  in  prolapse  of  the  iris.  The  prolapsed  portion  is  excised, 
the  operator  being  satisfied  with  removal  of  that  part  which  lies  exposed 
in  the  wound.  For  reasons  that  can  readily  be  understood,  we  avoid 
drawing  upon  the  prolapse  with  the  forceps.  The  wound  is  closed  by 
sewing  the  conjunctiva  over  it.  If  it  is  desired  to  introduce  scleral 
sutures,  they  must  include  only  the  superficial  layers  of  the  sclera,  so 
that  the  needle  does  not  produce  a  perforation  and  thus  cause  a  fresh 
injury  of  the  deeper  parts.  Scleral  sutures  are  usually  not  employed, 
as  the  pressure  necessary  to  pass  the  needle  through  the  sclera  causes 
further  protrusion  of  the  vitreous  which  lies  in  the  wound.  Scleral 
sutures  are  advisable  only  if  the  wound  gapes;  in  which  case  they  will 
prevent  the  formation  of  a  wide  cicatrix  that  would  likely  upon  con- 
traction lead  to  detachment  of  the  retina.  Absolute  rest  of  the  patient 
and  bandaging  of  both  eyes  during  the  first  few  days  are  necessary 
requisites  to  promote  healing  of  the  wound.  If  a  large  part  of  the  ciliary 
body  or  of  the  chorioid  has  prolapsed,  the  best  course  is  to  enucleate 
the  eyeball  at  once.  By  this  means  the  patient  is  relieved  of  a  long 
convalescence,  which  ends  with  an  atrophic  bulb  that  is  subject  t  o  re- 
peated attacks  of  pain  and  is  a  source  of  danger,  causing  sympathetic 
ophthalmia. 


PROLAPSE    OF    THE    IRIS.  215 

A  natural  question  is,  how  long  after  the  occurrence  of  the  pro- 
lapse may  excision  be  undertaken?  The  possibility  of  loosening 
the  prolapsed  iris  with  the  conical  sound  presupposes  a  loose  connection 
between  the  iris  and  the  edges  of  the  wound.  If  cicatrization  has 
advanced  too  far  the  undermining  with  the  sound  can  no  longer  be 
carried  out.  No  definite  time  can  be  stated.  Even  after  two  or  three 
weeks  a  slight  adhesion  may  be  found  between  the  prolapsed  iris  and 
the  edges  of  the  wound,  so  that  their  separation,  though  difficult,  is 
still  possible.  When  the  cicatrization  has  already  led  to  a  firm  union, 
so  that  an  ectatic  black  scar  is  seen  in  place  of  the  prolapse,  the  manner 
of  the  operative  interference  again  depends  materially  upon  the  size 
of  the  prolapse.  The  simplest  method  is  to  avoid  freeing  the  iris  from 
the  corneal  scar  and  to  perform  a  broad  iridectomy  behind  the  normal 
portion  of  the  cornea.  In  this  \vay  the  pressure  is  diminished,  and  by 
simultaneously  applying  a  pressure-bandage,  an  attempt  is  made  to 
produce  a  flat  cicatrix.  Although  this  simple  procedure  often  leads 
to  the  desired  result,  it  fails  in  many  cases,  for  the  ectasis  of  the  cicatrix 
sometimes  does  not  disappear  after  iridectomy,  and  the  eye  may  be 
destroyed  by  a  renewed  increase  in  pressure. 

For  these,  as  well  as  for  all  other  cases  of  anterior  synechia  (especially 
when  the  cicatrix  is  not  solid,  but  dimly  transparent  or  somewhat 
ectatic),  modern  ophthalmic  surgery  has  proposed  separation  of  the 
iris  from  the  cornea,  and  has  devised  various  methods  for  its  accomp- 
lishment. 

When  the  scar  is  small,  and  the  prolapse  the  size  of  a  fly's  head 
or  slightly  larger,  it  is  best  to  cut  off  the  protruding  cicatrix  with  a  lancet 
applied  flat  against  the  cornea.  The  opening  in  the  cornea  is  usually 
too  small  to  permit  the  introduction  of  iris-forceps  for  the  withdrawal 
and  excision  of  the  iris.  The  latter  is  better  accomplished  by  means 
of  a  blunt  hook.  After  its  excision,  either  the  iris  is  drawn  back  spon- 
taneously into  its  proper  position,  or  it  may  be  pushed  back  with  the 
blunt  tenaculum,  as  the  introduction  of  a  spatula  through  the  small 
opening  is  impossible.  The  small  wound  cicatrizes  in  a  short  time, 
and  the  anterior  chamber  is  usually  established  on  the  following  day. 

When  the  ectatic  cicatrix  is  large,  it  is  removed  with  the  lancet 
as  before,  and  the  iris  is  more  readily  excised  as  it  can  be  drawn  out 
with  the  forceps.  After  this  has  been  done,  the  defect  is  covered  with 
a  conjunctival  flap  as  already  described,  the  conjunctiva  replacing  the 
cicatrix. 


CHAPTER  XVIII. 
CORNEAL  TRANSPLANTATION.     KERATOPLASTY. 

Transplantation  of  the  cornea  consists  in  the  removal  of  the  cica- 
trix  and  its  replacement  by  healthy  corneal  tissue.  Fuchs  was  the  first 
to  recommend  that  the  fistulous  or  ectatic  cicatrix  be  excised  with  a 
corneal  trephine,  and  that  the  defect  be  covered  with  a  piece  of  cornea 
removed  by  a  trephine  from  a  freshly  enucleated  eye.  Before  cover- 
ing the  defect,  the  iris  must  be  freed  from  its  adhesions  to  the  cornea. 
If  the  patients  are  not  of  a  tranquil  nature,  it  is  necessary  to  perform 
the  operation  under  general  anesthesia,  in  order  to  avoid  any  increase 
of  intraocular  pressure  by  straining.  The  opening  is  made  with  a 
small  trephine-crown.  The  cutting  edge  of  the  trephine  should 
project  very  little,  in  order  to  avoid  going  too  deep  and  injuring  the 
capsule  of  the  lens.  The  eye  is  held  by  forceps,  and  the  trephine 
placed  with  slight  pressure  upon  the  cornea  in  the  region  of  the  cicatrix. 
The  assistant  then  presses  upon  the  button  of  the  trephine.  After 
a  few  rotations  the  instrument  must  be  raised  to  determine  the  depth 
of  the  cut,  and  to  observe  finally  if  the  instrument  has  perforated.  As 
the  scars  are  thin,  perforation  often  occurs  with  unexpected  rapidity. 
After  the  aqueous  humor  has  escaped,  if  the  circumscribed  piece  is 
not  cut  through  in  its  entire  circumference,  rather  than  to  re-apply  the 
trephine,  it  is  better  to  raise  the  flap  with  forceps  at  its  cut  end  and  care- 
fully separate  it  at  the  periphery  with  a  lancet.  This  is  not  difficult,  as 
a  rather  deep  furrow  will  have  been  made.  On  the  posterior  wall  of 
the  excised  piece  may  be  seen  adhering  the  remnants  of  the  pigmented 
epithelium,  in  accordance  with  the  circumstance  that  the  excised  cica- 
trix is  nothing  more  than  the  iris  which  has  undergone  cicatricial 
change. 

Carefully  avoiding  the  capsule  of  the  lens,  which  lies  exposed  in  the 
opening,  the  operator  then  proceeds  with  the  forceps  to  draw  the  iris 
out  a  trifle  on  all  sides,  and  to  excise  it  with  de  Wecker's  scissors. 
In  doing  this  there  is  the  danger  of  producing  an  iridodialysis,  especially 
if  the  iris  is  short  on  one  side.  This  is  most  likely  to  occur  when  the 
iris  is  roughly  drawn  out  with  the  forceps.  It  is,  therefore,  better  to 

216 


CORNEAL    TRANSPLANTATION.  217 

break  up  adhesions  with  a  blunt  tenaculum  and  thus  free  the  iris, 
whereupon  it  will  usually  withdraw  itself  from  the  scar,  or  it  may  be 
pushed  away  with  the  spatula.  .The  defect  is  then  covered  with  a 
piece  of  cornea  of  the  same  size,  removed  with  the  same  trephine  from 
a  freshly  enucleated  human  eye.  If  the  lens  does  not  protrude  it  is 
sufficient  to  insert  the  piece  without  further  fixation.  It  must  not  be 
forgotten  to  note  which  side  corresponds  with  the  outer  surface  i.e., 
which  side  is  covered  with  epithelium.  When  the  flap  is  placed  in  the 
proper  position,  the  upper  lid  is  drawn  down  carefully  over  the  eye, 
and  a  bandage  is  applied  to  both  eyes  and  is  not  removed  for  two 
days.  It  is  possible  that  the  flap  may  then  be  found  in  the  conjunctival 
sac  even  though  it  may  originally  have  lain  in  the  correct  position.  But 
in  the  large  majority  of  cases  it  remains  fixed. 

It  may  be  seen,  however,  during  the  operation,  that  the  flap  shows  no 
tendency  to  remain  over  the  opening.  This  is  especially  the  case  if 
the  lens  or  the  hyaloid  membrane  protrudes,  the  latter  in  case  the  lens 
is  wanting.  Under  these  circumstances  the  flap  must  be  fixed  in 
position  by  a  flap  of  conjunctiva,  as  already  described,  this  conjunctiva 
serving  the  purpose  of  pressing  the  corneal  flap  upon  its  foundation 
during  the  first  few  days.  The  conjunctival  flap  must  not  be  too  small. 
A  scanty  flap  cannot  be  sufficiently  stretched,  and,  as  it  always  has  the 
tendency  to  slip  off  from  the  bulging  cornea,  it  may  even  lead  to  a  dis- 
location of  the  corneal  flap.  The  conjunctival  piece  should  be  at  least 
half  again  as  wide  as  the  corneal  flap.  Moreover,  as  the  conjunctiva 
retracts  when  cut  through,  it  is  necessary  in  planning  the  conjunctival 
incision  to  circumscribe  a  strip  fully  twice  as  wide  as  the  diameter  of 
the  corneal  flap.  The  conjunctiva  in  these  cases  lies  upon  a  surface 
completely  covered  with  epithelium.  There  is,  therefore,  no  adhesion 
between  the  two,  and  if  the  sutures  have  not  spontaneously  cut  through, 
in  the  meantime,  the  conjunctival  flap  may  be  loosened  in  a  few  days 
and  returned  to  its  original  position  or  excised.  In  every  case  of  cor- 
neal transplantation  both  eyes  should  be  kept  bandaged  for  at  least 
four  days,  and  the  patient  should  remain  in  bed.  The  transplanted 
flap  becomes  cloudy  in  the  course  of  time,  but  it  retains  its  firmness. 
By  means  of  this  operation,  therefore,  not  only  is  the  dangerously 
yielding  and  leaking  scar  removed  and  replaced  by  solid  tissue,  but 
also  the  iris  has  been  freed  from  adhesions. 

Partial  keratoplasty  consists  in  removing,  by  means  of  the  trephine, 
a  flap  of  cornea  which  does  not  include  its  whole  thickness,  sparing 


2l8  OPHTHALMIC    SURGERY. 

Descemet's  membrane  at  least.  This  method  has  been  perfected 
especially  by  v.  Hippel.  It  is  suitable  only  for  those  cases  in  which 
the  cicatricial  clouding  of  the  cornea  that  is  to  be  replaced  by  a  trans- 
parent piece  does  not  include  the  whole  thickness  of  the  cornea.  By 
means  of  the  trephine  (the  crown  of  which  should  never  exceed  4  mm. 
in  diameter)  a  groove  is  cut  to  the  required  depth.  The  flap  is  then 
carefully  cut  out  with  the  aid  of  forceps  and  a  lancet  applied  flat,  the 
result  being  that  the  transparent  posterior  layer  of  the  cornea  lies 
exposed  in  the  defect.  A  corneal  segment  of  the  same  size  is  then  ex- 
cised in  its  whole  thickness  from  a  suitable  freshly-enucleated  human  eye. 
The  defect  is  covered  with  this  piece.  The  eyes  are  carefully  closed 
and  bandaged,  the  bandage  being  changed  in  three  days.  It  can  be 
entirely  dispensed  with  in  nine  days.  The  adhesion  of  the  transplanted 
piece  usually  occurs  promptly,  but  the  expectation  that  the  flap  will 
remain  transparent  is  almost  never  realized.  A  complete  cloudiness 
gradually  develops. 

Total  Keratoplasty. — In  this  operation  the  scar  is  excised  for  the 
whole  thickness  of  the  cornea  and  is  replaced  by  a  transparent  flap. 
In  this  case  also  the  flap  usually  adheres  well,  but  the  cloudiness  becomes- 
complete  in  a  short  time.  From  an  optical  point  of  view,  therefore, 
these  operations  are  at  present  almost  worthless.  They  are  employed 
only  to  replace  a  fistulous  or  ectatic  part  of  the  cornea. 

The  trephine  of  v.  Hippel  contains  a  drum  at  its  upper  end,  in 
which  a  clock-work  arrangement  is  introduced.  On  the  cover  of  the 
drum  is  placed  a  button;  by  pressing  on  this  button  with  the  finger,  the 
crown  of  the  trephine  is  set  into  rapid  rotation.  This  crown  can  be 
varied  in  height,  thus  regulating  at  will  the  depth  of  the  incision.  The 
trephine  contains  a  set  of  crowns  of  varying  size. 

It  is  evident  that  the  operation  for  removal  of  an  ectatic  cicatrix  with 
the  trephine  can  only  be  applied  to  scars  of  small  circumference;  i.e., 
with  a  maximum  diameter  of  4  mm.  If  a  large  piece  is  trephined 
from  the  cornea,  the  transplanted  flap  usually  will  not  hold,  and  the 
large  opening  will  have  to  be  covered  later  by  a  conjunctival  flap. 
Therefore,  for  large  ectatic  scars  there  remains  only  the  original  simple 
method  of  producing  a  flattening  of  the  scar  by  a  broad  iridectomy 
and  subsequent  pressure-bandage.  Ectatic  cicatrices  should  be 
removed  by  operative  means,  as  they  not  only  carry  with  them  the  dan- 
ger of  increased  pressure,  but  also  afford  a  portal  of  entry  for  infection 
of  the  eye.  But  increase  in  pressure  may  also  occur  in  cases  of  anterior 


CORNEAL    TRANSPLANTATION.  2 19 

synechia,  in  which  the  corneal  scar  is  not  only  flat  but  also  solid,  espe- 
cially if  a  considerable  portion  rather  than  a  small  tip  of  the  iris  is 
adherent  to  the  scar. 

Operations  for  Anterior  Synechia.— It  is  difficult  to  give  a  general 
rule  for  operative  interference  in  anterior  synechia — a  flat  cicatrix 
being  naturally  implied.  It  has  already  been  explained  that  an  ectatic 
scar  should  be  subjected  to  operation  under  all  circumstances.  But 
there  occurs  the  question,  should  an  operation  be  performed  in  every 
case  of  anterior  synechia  with  flat  solid  cicatrix?  By  no  means  is  this 
our  belief.  In  deciding,  the  following  are  considered  indications: 
(i)  If  the  fusion  is  extensive,  so  that  a  large  part  of  the  pupillary  border 
is  adherent  to  the  cicatrix.  (2)  If  signs  of  increased  pressure  are  pres- 
ent even  though  they  occur  but  intermittently.  (3)  If  the  cicatrix, 
although  originally  flat,  threatens  to  yield  to  the  intra-ocular  pressure 
(beginning  protrusion).  (4)  If  dislocation  of  the  pupil,  as  a  result  of 
distortion  of  the  iris,  hides  the  pupillary  opening  completely  behind 
the  cicatrix.  The  latter  may  occur  in  a  peripheral  adhesion  of  the  iris, 
when  the  pupil  is  so  distorted  that  only  the  irregular  refracting  border 
of  the  cornea  can  be  used  for  visual  purposes.  The  same  visual  dis- 
turbance occurs  when  the  pupil  is  directly  covered  by  a  central  corneal 
cicatrix.  In  the  fourth  indication,  the  operation  is  demanded  upon 
essentially  optical  grounds.  While  we  were  formerly  well  satisfied 
with  iridectomy  in  all  these  cases,  we  now  prefer  a  temporary  resec- 
tion of  the  cicatrix  with  the  aid  of  the  trephine — a  method  which  was 
first  recommended  by  Sachs.  As  the  scar  is  solid,  it  does  not  require 
to  be  replaced  by  a  piece  removed  from  another  cornea. 

In  order  to  avoid  the  danger  of  delayed  healing  of  the  excised  flap 
of  cornea,  it  is  only  separated  in  a  little  more  than  half  its  circum- 
ference by  placing  the  trephine  obliquely  upon  the  cornea.  In 
this  way  an  assistant  may  lift  the  flap  like  a  lid  with  a  sharp  tenaculum, 
while  through  the  opening  thus  produced  the  operator  enters  the 
anterior  chamber  with  the  forceps  or  a  tenaculum,  draws  the  iris  care- 
fully out  o  n  all  sides  and  excises  it.  The  base  of  the  flap  is  so  placed 
that  the  iris  can  be  most  readily  reached  through  the  opening  produced 
by  lifting  the  flap.  In  most  cases,  therefore,  this  base  will  lie  toward 
the  center;  that  is,  toward  the  pupil.  After  the  iris  is  completely  freed, 
the  flap  is  returned  to  its  original  position,  in  which  it  is  firmly  held 
by  the  pressure  of  the  upper  lid  when  the  eye  is  closed.  A  light  com- 
press and  bandage  may  be  used  to  support  the  lid.  By  the  use  of 


220  OPHTHALMIC    SURGERY. 

atropin  an  attempt  is  made  to  retract  the  iris  as  far  as  possible  from 
its  former  point  of  adhesion.  The  anterior  chamber  will  be  re-estab- 
lished on  the  next  day,  but  it  is  advisable  to  keep  the  eye  bandaged 
for  at  least  one  week.  The  corneal  cicatrix,  which  was  formerly 
somewhat  thin  and  had  already  become  slightly  ectatic,  is  often  observed 
to  become  flat  and  solid  after  this  operation.  After  detachment  of 
the  iris  from  the  cicatrix,  the  former  withdraws,  and  the  pupil  returns 
to  its  position  behind  the  center  of  the  cornea.  Therefore,  by  this 
means  not  only  have  the  optical  disturbances  been  remedied,  but  also 
the  anterior  synechia  is  removed.  When  the  eye  has  become  entirely 
free  from  inflammation,  and  healing  is  complete,  a  tattooing  of  the  scar 
may  be  performed. 

The  only  danger  in  trephining  the  cornea  lies  in  an  injury  to  the 
lens.  Sometimes,  unfortunately,  this  cannot  be  avoided,  as,  for  in- 
stance, when  the  lens-capsule  is  adherent  to  the  scar,  and  the  capsule  is 
cut  when  the  corneal  cicatrix  is  incised.  But  in  these  very  cases  the 
injury  to  the  lens  is  not  so  important,  as  this  structure  is  usually 
cloudy  and,  in  young  persons,  frequently  shrunken.  The  most  dreaded 
sequel  occurs  after  the  escape  of  the  lens-substance,  when  the  delicate 
hyaloid  membrane  appears  in  the  wound  and  ruptures,  leading  to 
prolapse  of  the  vitreous  humor  and  preventing  continuance  of  the 
operation. 

If  the  adhesion  of  the  iris  consists  merely  of  a  fine  filament  which, 
for  example,  unites  the  anterior  surface  of  the  iris  with  a  solid  corneal 
cicatrix,  a  division  of  this  attachment  is  certainly  not  necessary.  The 
same  holds  true  of  an  adhesion  between  a  small  part  of  the  pupillary 
border  and  the  cornea,  provided  that  the  cicatrix  itself  is  in  good  condi- 
tion. Moreover,  these  are  the  cases  in  which  the  anterior  synechia  can 
be  divided  by  the  simpler  means  of  the  discission  needle  or  the  Graefe's 
knife. 

In  cases  of  anterior  synechia  produced  by  the  iris  healing  in  an  oper- 
ation-cicatrix,  the  mode  of  procedure  cannot  be  governed  by  any 
general  fixed  rules.  The  point  of  view  to  be  taken  may  perhaps  be 
more  readily  comprehended  from  several  examples:  After  an  iridec- 
tomy  for  glaucoma,  in  which  one  or  both  sides  of  the  excision  have  be- 
come adherent  to  the  wound,  no  additional  interference  is  called  for  if 
tension  is  normal  and  the  operative  cicatrix  remains  flat,  presenting 
at  most  a  dark  coloration  of  the  scar  due  to  the  adhesion  of  the  iris. 
If  fresh  attacks  of  increased  pressure  arise,  it  would  be  a  mistake  to 


CORNEAL    TRANSPLANTATION.  221 

proceed  immediately  to  the  performance  of  a  second  iridectomy,  .as 
the  latter,  being  carried  out  inferiorly,  would  exert  an  unfavorable 
influence  upon  the  visual  function.  Here,  however,  it  is  necessary 
to  remove  the  adhesion  of  the  iris. 

The  first  method  of  operation  consists  in  making  with  a  lancet 
an  incision  corresponding  to  the  adherent  side  of  the  coloboma;  this 
incision  should  be  as  near  the  periphery  as  possible.  Then  the  iris  is 
drawn  out  with  the  iris-forceps  and  excised,  whereupon  it  either  spon- 
taneously returns  to  its  proper  position  or  is  replaced  with  a  spatula. 

The  second  method  takes  into  consideration  the  possibility  of  an 
injury  to  the  lens,  and  is,  therefore,  safer.  An  incision  is  made  in  the 
region  of  the  iris-adhesion  similar  to  that  of  an  anterior  sclerotomy. 
A  Graefe  knife  is  introduced  on  one  side  of  the  adhesion,  and  is  brought 
out  of  the  anterior  chamber  on  the  other  side  of  the  adhesion,  and 
makes  a  scleral  cut  as  near  the  periphery  as  possible,  so  that  the  iris  is 
thereby  severed  from  its  adhesion.  The  incision  need  not  be  com- 
pleted. Especially  when  a  prolapse  of  the  vitreous  humor  is  to  be  feared, 
the  flap  should  not  be  completely  cut  through,  in  order  to  avoid  a  gap- 
ing wound.  If  the  iris  does  not  retract  after  the  incision,  this  method 
also  permits  the  operator  to  draw  the  iris  out  with  tenaculum  or  forceps 
to  excise  it  to  its  proper  position. 

Operation  for  cystic  scars  after  iridectomy  for  glaucoma 
is  at  present  much  under  debate.  Some  authorities  consider  these 
cicatrices  with  their  porous  and  nitrating  properties  favorable  occur- 
rences in  glaucomatous  eyes,  and  do  not  remove  them  unless  forced  to 
do  so.  Others  maintain  that  it  is  better  to  free  the  iris  and  produce  a 
flat  cicatrix,  thus  protecting  the  eye  from  other  dangers  that  may 
arise  from  cystic  scars,  especially  the  danger  of  spontaneous  late 
infection. 


CHAPTER  XIX. 

EXTRACTION  OF  FOREIGN  BODIES  FROM  THE  INTERIOR 

OF  THE  EYE. 

The  extraction  of  foreign  bodies  from  the  interior  of  the  eye  is 
usually  a  most  delicate  operation,  particularly  if  attempted  weeks 
or  months  after  the  original  injury.  There  is  no  typical  operative 
method  that  may  guide  the  less  skillful,  and,  as  many  of  the  most 
important  structures  of  the  eye  are  directly  or  indirectly  affected  in 
any  form  of  operation,  these  may  readily  receive  more  injury  than  aid 
from  the  operator  of  limited  experience. 

Diagnosis. — In  many  cases  one  can  recognize  at  first  glance  a 
perforation  of  the  eyeball  by  a  foreign  body  and  determine  the  pres- 
ence of  the  latter  within  the  eye,  but  in  others  it  may  be  difficult  to 
find  the  point  of  entrance  and  to  discover  the  foreign  body  itself. 
It  frequently  happens  that  a  patient  will  complain  of  diminution  in 
visual  power  without  known  cause  and  with  positive  denial  of  any 
injury,  while  the  skilled  eye  of  the  physician,  warned  by  the  finding 
of  a  unilateral-partial  cataract,  will  examine  the  eye  with  a  magnifying 
glass  and  at  once  discover  a  positive  sign  of  previous  penetrating  wound 
in  the  form  of  a  fine  linear  corneal  cicatrix.  If  the  media  is  sufficiently 
transparent  to  permit  an  ophthalmoscopic  examination,  the  splinter 
will  be  found  in  the  vitreous  or  retina.  Naturally  even  the  most 
experienced  surgeon  may  in  some  cases  only  succeed  after  prolonged 
efforts. 

Often  a  vain  search  is  made  for  the  cicatrix.  A  fine  narrow  splinter 
with  sharp  edges,  penetrating  the  sclera  at  the  limbus  or  through  the 
bulbar  conjunctiva,  will  leave  behind  not  the  slightest  trace  of  a 
visible  cicatrix.  The  diagnosis  will  then  depend  upon  the  exami- 
nation with  the  ophthalmoscope,  the  sideroscope  and  the  Rontgen  rays. 
An  advanced  cataract  may  render  impossible  the  illumination  of  the 
eye-ground  and  the  consequent  discovery  of  the  foreign  bcdy.  Again, 
the  lens  may  remain  transparent  in  spite  of  a  perforating  injury; 
namely,  if  the  perforation  has  occurred  through  the  sclera  without 
injuring  the  lens.  However,  the  diagnosis  may  be  rendered  difficult 

222 


EXTRACTION    OF    FOREIGN    BODIES.  223 

through  the  presence  of  dense  vitreous  turbidity,  which  is  usually 
greatest  around  a  foreign  body  lodged  posteriorly  in  the  eyeball.  Or 
the  difficulty  in  diagnosis  may  be  due  to  the  separation  of  the  retina, 
which  occurs  frequently  in  such  injuries.  An  exact  and  complete 
diagnosis,  including  the  localization  of  the  splinter,  is  most  readily 
made  when  the  opportunity  is  afforded  of  examining  the  patient  im- 
mediately after  the  injury.  Under  these  conditions,  even  if  the  lens 
is  pierced,  it  is  frequently  possible,  in  spite  of  beginning  lenticular 
turbidity,  to  find  the  splinter  by  means  of  the  ophthalmoscope  in  the 
vitreous  or  in  the  retina. 

The  position  of  the  foreign  body  does  not  always  correspond  to  the 
direction  indicated  by  the  corneal  wround  and  the  turbidity  of  the  lens. 
It  frequently  happens  that  the  splinter  has  been  deprived  of  its  momen- 
tum through  resistance  of  the  cornea  and  lens,  and  simply  falls  to  the 
bottom  of  the  vitreous  chamber.  On  the  other  hand,  it  may  have  been 
projected  as  far  as  the  retina  without  penetrating  the  latter,  and  may 
have  sunk  downward  from  the  point  of  impact.  It  is,  therefore,  always 
advisable  to  examine  first  the  fundus,  especially  in  the  direction  of  the 
corneal  and  lenticular  wounds.  Here  there  may  be  discovered  a 
wound  in  the  retina  and  chorioid,  appearing  as  a  glistening,  white  spot 
(the  exposed  sclera),  which  may  even  assume  the  form  of  the  foreign 
body;  or  there  may  at  least  be  seen  a  hemorrhage  corresponding  to  the 
point  of  impact. 

In  most  cases  the  foreign  body  is  a  splinter  of  metal,  which  is  ren- 
dered conspicuous  by  its  metallic  luster,  as  its  outer  surface  reflects 
light  strongly.  In  recent  cases,  air-bubbles  may  not  infrequently, 
be  seen  in  the  vitreous  or  around  the  foreign  body.  If  a  dense  opacity 
of  the  vitreous  lies  in  front  of  the  foreign  body,  the  position  of  the 
latter  is  betrayed  by  a  conspicuous  whitish  luster.  In  presence  of  iron- 
splinters  within  the  eye,  the  sideroscope  renders  valuable  assistance; 
it  not  only  indicates  the  presence  of  small  particles,  but  also  at  the 
same  time  allows  an  incidental  localization,  manifested  by  a  marked 
deviation  of  the  magnetic  needle  upon  approaching  the  position  of  the 
fragment. 

However,  the  deviation  of  the  magnetic  needle  does  not  always 
indicate  the  presence  of  a  splinter  within  the  eyeball.  We  have 
recently  seen  an  illustrative  case  in  which  a  patient  declared  that  he 
had  been  wounded  by  a  splinter  while  hammering  on  iron  two  months 
previously.  The  splinter  penetrated  the  lower  lid  about  8  mm. 


224  OPHTHALMIC    SURGERY. 

below  the  edge  of  the  lid.  The  wound  bled  slightly,  and  it  was  on  y 
after  the  lapse  of  some  time  that  the  patient  noticed  a  gradual  dimi- 
nution in  the  visual  power  of  this  eye,  without  having  experienced  any 
inflammation.  When  the  patient  was  seen  for  the  first  time,  there  was 
found  a  delicate  scar  in  the  skin  of  the  lower  lid  about  3  mm.  in  length. 
No  cicatrix  could  be  found  on  the  eye  by  the  minutest  examination, 
but  the  vision  was  about  one-fourth  normal.  By  means  of  the  ophthal- 
moscope, floating  vitreous  opacities  could  be  seen,  which  were  fixed 
below  and  moved  about  freely  in  the  upper  part  of  the  eyeball.  Upon 
looking  downward,  the  red  reflex  was  lost  entirely,  on  account  of 
increasing  density  of  the  opacities.  As  the  visual  field  was  much 
limited  in  its  upper  part,  a  separation  of  the  retina  in  this  region  seemed 
probable.  The  splinter  could  not  be  seen.  The  patient  was  placed 
in  front  of  the  sideroscope.  Upon  approaching  it,  the  needle  was 
immediately  affected,  and  showed  a  marked  deviation.  This  occurred 
with  almost  the  same  intensity  in  all  positions  of  the  eyeball,  but 
was  greatest  when  the  patient  was  brought  near,  with  the  eye  directed 
upward.  But  in  front  of  the  large  magnet  even  the  strongest  currents 
did  not  draw  out  the  splinter,  and  the  patient  did  not  have  the  slightest 
pain.  This  was  more  remarkable,  since  the  presence  of  a  large  splinter 
had  been  assumed  from  the  size  of  the  palpebral  cicatrix  and  the 
deviation  of  the  sideroscope.  However,  examination  with  the  Ront- 
gen  rays  showed  that  actually  a  splinter  5  mm.  long  was  lodged  in  the 
orbit  outside  of  the  eyeball.  In  its  course  through  the  orbit  the  splinter 
either  had  perforated  the  sclera  twice,  or  had  slit  up  the  envelope  of  the 
eyeball  below,  and  had  thus  produced  the  intra-ocular  changes. 

The  extraction  of  iron  splinters  by  the  magnet  operation  will 
first  be  described.  When  the  iron  splinter  is  found  in  the  vitreous 
chamber  or  in  the  retina,  the  method  employed  exclusively  in  our  clinic 
consists  in  first  drawing  this  splinter  into  the  anterior  chamber  by 
means  of  the  large  magnet  (Haab) .  This  operation  must  be  carefully 
performed,  in  order  that  the  eye  shall  not  receive  disastrous  injury. 
There  are  two  means  at  our  command  to  lessen  the  attractive  power 
of  the  large  magnet  on  the  eye,  either  by  employing  a  weak  current 
so  that  the  iron  core  is  given  but  slight  magnetic  pull,  or  by  keeping 
the  eye  at  some  distance  from  the  pole  of  the  magnet.  The  object 
is  to  use  the  least  possible  magnetic  force  necessary  to  draw  the  splinter 
gently  around  the  edge  of  the  lens,  first  behind  the  iris  and  then 
through  the  pupil  into  the  anterior  chamber.  If  the  position  of  the 


EXTRACTION    OF    FOREIGN    BODIES.  225 

splinter  has  been  determined,  it  is  not  difficult  to  rotate  the  eye  into 
the  proper  position.  For  example,  if  the  splinter  lies  in  the  lower 
part  of  the  vitreous  chamber,  the  eye  will  be  directed  downward  upon 
approaching  the  magnet,  so  that  the  latter  is  brought  approximately 
opposite  the  center  of  the  cornea.  If  the  injury  has  occurred  recently, 
the  splinter  will  very  soon  follow  the  magnet,  and  will  appear  behind 
the  iris,  causing  a  protrusion  of  the  latter.  If  the  injury  is  of  longer 
duration,  it  may  take  some  time  before  the  splinter  yields  to  the  traction 
of  the  magnet.  If  it  is  seen  that  the  extraction  cannot  be  accom- 
plished with  mild  currents,  the  strength  of  the  latter  is  gradually 
increased.  But  if  the  patient  experiences  pain  even  with  a  mild  current 
this  is  an  indication  that  the  splinter  is  yielding,  and  is  perhaps  in 
contact  with  the  ciliary  body;  greater  care  must  then  be  taken  in  the 
operation.  If  the  foreign  body  has  become  firmly  lodged  in  the 
posterior  eye-ground  by  means  of  inflammatory  bands,  even  the  large 
magnet  may  not  be  sufficient  to  dislodge  it,  especially  if  the  splinter 
is  very  small.  It  may  then  be  necessary  to  subject  the  patient  to  the 
magnet  repeatedly,  and  each  time  for  a  longer  period,  before  we 
succeed  in  drawing  the  splinter  gradually  from  its  bed. 

Having  been  drawn  into  the  anterior  chamber,  the  splinter  may  be 
pulled  by  force  of  the  magnet  to  the  posterior  wall  of  the  cornea,  where 
it  remains  hanging;  or  it  may  fall  upon  the  iris  or  into  the  angle  of  the 
chamber,  where,  if  sufficiently  small,  it  may  entirely  disappear  from 
view.  To  remove  the  splinter  from  the  anterior  chamber,  an  incision 
is  made  with  the  lancet,  usually  below,  and  of  sufficient  size  so  that  an 
instrument,  such  as  forceps  or  the  end  of  a  small  magnet,  may  readily 
be  introduced  without  compressing  the  iris  or  cornea.  It  is  best  to 
attempt  to  combine  the  incision  and  the  extraction  of  the  foreign  body 
in  one  act.  The  assistant  by  means  of  the  small  magnet  holds  the 
splinter  against  the  center  of  the  posterior  corneal  wall,  while  the 
operator  introduces  the  lancet.  At  the  moment  when  the  operator 
begins  to  withdraw  the  lancet  from  the  eye,  the  assistant  moves  the 
magnet  downward  along  the  outer  surface  of  the  cornea,  so  that  the 
splinter  makes  its  exit  from  the  wound  along  the  outer  surface  of  the 
lancet  simultaneously  with  the  latter. 

A  negative  result  from  the  examination  with  the  sideroscope  is  not 
always  to  be  accepted  as  a  certainty  that  no'  steel  is  in  the  eyeball  or 
orbit;  a  slight  deviation  may  frequently  have  no  significance,  especially 
in  large  cities,  where  the  magnetic  needle  is  always  in  a  state  of  unrest. 


226  OPHTHALMIC    SURGERY. 

Penetrating  wounds  of  the  eyeball  are  often  made  with  splinters 
of  other  materials,  such  as  wood,  stone  and  especially  copper,  which 
may  penetrate  the  eye  from  an  explosion  of  percussion  caps.  If  these 
splinters  lodged  in  the  posterior  section  of  the  eyeball,  until  recently 
the  eye  was  usually  looked  upon  as  lost;  and  if  it  was  certain  that  such 
an  intra-ocular  foreign  body  was  present,  an  enucleation  was  imme- 
diately performed.  Examination  with  the  Rontgen  rays  has  since 
effected  a  great  change  in  the  treatment  of  these  cases,  and  has  made  it 
possible  to  save  many  eyes  that  were  formerly  regarded  as  lost.  Without 
a  previous  examination  with  the  Rontgen  rays,  no  operation  should 
be  undertaken  in  any  case  where  there  is  suspicion  of  an  intra-ocular 
foreign  body,  with  perhaps  the  exception  of  an  iron  splinter.  By  this 
examination  there  is  also  given  us  accurate  information  concerning  the 
position  of  the  splinter. 

Summary — In  concluding  these  observations,  it  may  be  said  in 
general  that  the  presence  of  small  wounds  caused  by  the  impact  of 
foreign  bodies  usually  points  to  the  likelihood  of  these  bodies  having 
entered  the  eye;  while  in  patients  showing  large  wounds  the  injury  is 
caused  by  larger  pieces  which  rebound  and  do  not  remain  in  the  eye. 
For  example,  if  a  recent  injury  of  the  cornea  is  found  in  the  form  of  a 
small  perforating  wound,  and  if  the  history  is  obtained  that  a  small 
splinter  had  come  in  contact  with  the  eye,  such  circumstances  will 
allow  the  presumption  that  there  is  a  foreign  body  within  the  eye. 
If  it  is  not  found  lying  in  the  anterior  chamber,  the  search  for  a  per- 
foration of  the  iris,  lens-capsule,  etc.,  will  not  be  in  vain.  On  the 
other  hand,  a  larger  piece,  flying  against  the  eye  with  its  fine  point, 
might  wound  the  cornea,  iris  and  lens-capsule  and  then  drop  away. 
In  this  case  the  patient's  statement  concerning  the  size  of  the  splinter 
is  of  importance. 

Unfortunately,  the  result  with  the  small  magnet  is  often  unsatis- 
factory. It  is  not  sufficiently  strong  to  exert  its  magnetic  power 
through  the  cornea  and  to  direct  the  splinter  at  will.  If  the  attempt 
just  described  is  not  successful,  the  splinter  may  be  drawn  out  of  the 
anterior  chamber  through  the  wound  by  means  of  the  magnet.  The 
tip  of  the  magnet  is  introduced  through  the  wound  into  the  anterior 
chamber  and  brought  close  to  the  foreign  body,  so  that  the  force  is 
sufficient  to  attract  the  splinter.  As  the  various  terminals  of  the  mag- 
net are  relatively  thick,  it  is  less  injurious  to  grasp  the  foreign  body 
directly  with  a  pair  of  forceps  and  thus  withdraw  it.  Occasionally 


EXTRACTION    OF    FOREIGN    BODIES.  227 

the  splinter  can  be  removed  with  the  aid  of  Daviel's  curette.  This 
instrument  is  introduced  behind  the  foreign  body,  presses  it  against 
the  posterior  corneal  wall,  and  renders  its  extraction  easy  along  the 
channel  formed  by  the  curette.  In  all  these  procedures  care  must  be 
taken  not  to  allow  the  splinter  to  disappear  behind  the  iris,  either  by 
falling  downward  or  by  being  pushed  upward  behind  the  pupil  by  the 
use  of  an  instrument.  In  order  to  bring  again  to  view  the  foreign 
body,  recourse  must  usually  be  had  again  to  the  large  magnet,  espe- 
cially if  a  minute  splinter  has  disappeared  below  into  the  bottom  of  the 
chamber.  The  iris  is  to  be  excised  only,  if  severely  injured  by  the 
accident,  or,  as  rarely  occurs,  it  has  been  badly  contused  during  the 
operation.  If  the  foreign  body  has  perforated  the  lens  and  the  wound 
in  the  capsule  becomes  closed  by  the  iris,  the  opacity  in  the  lens  may 
remain  slight  and  stationary.  In  this  case  that  part  of  the  iris  which 
covers  the  wound  in  the  capsule  should  be  carefully  avoided  during 
the  operation. 

Extraction  from  the  vitreous  through  the  anterior  chamber  is  contra- 
indicated  only  if  the  foreign  body  has  penetrated  the  sclera  behind 
the  lens,  so  that  the  latter  has  remained  completely  transparent.  In 
this  case  the  splinter  is  withdrawn  directly  through  the  original  wound 
by  means  of  the  large  magnet,  applied  as  described.  If  necessary, 
the  wound  can  be  enlarged  to  a  sufficient  size.  Only  by  gross  care- 
lessness on  the  part  of  the  operator  will  parts  of  the  chorioid  and 
retina  be  withdrawn  with  the  foreign  body.  If  the  magnet  is  made 
sufficiently  weak,  the  splinter  can  slowly  be  brought  into  the  wound 
whence  it  may  be  readily  extracted. 

Some  operators  believe  that  extraction  through  an  opening  in  the 
sclera,  preferably  between  the  external  and  inferior  recti  muscles,  with 
the  magnet-point  between  the  lips  of  the  wound,  but  not  entered  into 
the  vitreous,  is  a  safer  procedure  than  removal  of  the  foreign  body 
around  the  lens  into  the  anterior  chamber.  This  is  the  method  largely 
followed  in  America,  the  position  of  the  metal  being  accurately  deter- 
mined by  means  of  the  Roentgen-rays  before  operation. 

Prognosis. — The  smaller  the  splinter,  the  more  favorable  is  the  prog- 
nosis for  the  future  of  the  eye.  Large  splinters  render  the  prognosis 
bad,  because  of  the  immediate  injury  to  important  parts  of  the  eye,  and 
the  subsequent  inflammation  that  occurs.  Even  though  their  extraction 
may  have  been  performed  smoothly,  separation  of  the  retina  or  chronic 
iridocyclitis  may  follow,  usually  necessitating  enucleation  of  the  eye. 


228  OPHTHALMIC    SURGERY. 

Foreign  bodies  other  than  iron  that  lodge  in  the  anterior  section 

of  the  eye,  may  in  exceptional  cases  be  extracted  through  the  original 
wound  in  the  cornea,  after  its  enlargement  by  means  of  scissors. 
Only  peripheral  wounds,  however,  are  suitable  for  this  procedure. 
Wounds  near  the  center  of  the  cornea  if  similarly  treated  would  later 
produce  still  greater  disturbance  of  vision  through  the  larger  cicatrix 
resulting  from  the  incision,  and  it  is,  therefore,  the  best  procedure  to 
make  a  lancet-incision  elsewhere  of  sufficient  size  to  permit  the  intro- 
duction of  forceps.  This  incision  may  be  difficult  if  the  wound  pro- 
duced by  the  foreign  body  has  not  yet  closed,  permitting  escape  of  the 
aqueous  and  shallowing  of  the  anterior  chamber.  But  even  then  a 
correct  incision  can  be  made  between  the  cornea  and  iris  without 
wounding  the  latter,  especially  if  a  Graefe  knife  is  used  and  is  slowly 
introduced  between  both  membranes.  If  the  splinter  in  the  anterior 
chamber  is  large  and  warped,  care  must  be  taken  during  its  with- 
drawal not  to  wound  the  iris  or  capsule  of  the  lens.  The  incision  into 
the  anterior  chamber  is  best  made  below  or  externally,  from  which 
directions  instruments  can  be  most  readily  introduced  into  the  eye. 

The  extraction  from  the  vitreous  chamber  of  foreign  bodies  not 
composed  of  iron  is  incomparably  more  complicated.  Such  substances 
are  usually  splinters  of  copper  or  grains  of  shot.  Before  operating  for 
their  removal,  they  must  be  accurately  localized,  using  the  Roentgen 
rays  for  this  purpose.  On  account  of  their  weight,  most  of  these  for- 
eign bodies  fall  to  the  bottom  of  the  vitreous  chamber,  where  they 
immediately  become  fixed  by  exudate.  They  can  most  readily  be 
recovered,  if  they  lie  externally  and  below.  The  operative  procedure 
is  as  follows:  After  an  incision  into  the  conjunctiva  and  uncovering 
of  the  sclera,  a  meridional  opening,  at  least  6  to  8  mm.  long,  is  made 
in  the  neighborhood  of  the  foreign  body,  the  cut  extending  through 
the  sclera  into  the  vitreous  humor.  With  double  tenacula  the  assistant 
raises  and  separates  the  edges  of  the  wound,  in  order  to  facilitate  an 
examination  of  the  interior  of  the  eye.  During  this  procedure  the 
loss  of  vitreous  humor  can  readily  be  avoided.  It  is  best  to  have  the 
patient  in  condition  of  profound  anesthesia. 

If  the  incision  corresponds  with  the  position  of  the  foreign  body, 
the  latter  will  appear  in  the  wound  and  can  be  removed  with  forceps. 
But  if  it  has  not  appeared  in  the  wound,  the  attempt  to  find  it  in  the 
vitreous  chamber  is  usually  hopeless.  The  immediate  neighborhood 
of  the  wound  must  be  carefully  explored  with  the  iris-forceps,  in  the 


EXTRACTION    OF    FOREIGN    BODIES.  22Q 

hope  of  locating  the  foreign  body.  Occasionally,  the  use  of  Sach's 
lamp  will  be  of  material  assistance  in  the  operation.  If  the  lamp 
is  placed  by  an  assistant  laterally  against  the  cornea,  without  exerting 
pressure  on  the  eye,  the  open  incision  and  the  whole  vitreous  space  is 
illuminated  and  transparent,  so  that  in  fortunate  cases  the  foreign 
body  is  recognized  as  a  dark  structure,  and  can  be  grasped  and  with- 
drawn with  the  forceps.  After  the  extraction  it  is  necessary  to  suture 
the  scleral  wound  accurately  through  the  superficial  layers,  and  to 
sew  the  conjunctiva  over  it.  The  patient  should  be  kept  in  bed  for 
several  days.  The  prognosis  even  in  successful  cases  is  bad  on 
account  of  detachment  of  the  retina. 

If  the  extraction  of  the  foreign  body  has  not  been  accomplished, 
it  is  best  to  proceed  at  once  to  the  enucleation.  The  consent  of  the 
patient  to  this  operation  should  be  obtained  beforehand,  telling  him 
that  the  other  procedure  is  merely  an  attempt  to  save  the  eye  through 
search  for  and  extraction  of  the  foreign  body.  Non-magnetic  foreign 
bodies  situated  in  the  neighborhood  of  the  macula  give  no  hope  of 
extraction  with  preservation  of  the  eye. 

In  all  recent  injuries,  whether  the  splinter  is  of  iron  or  of  other 
material,  immediate  operation  should  be  undertaken.  It  is  other- 
wise, however,  with  old  injuries.  We  know  that  splinters  of  iron 
are  not  well  borne,  but  cause  a  gradual  disintegration  of  the  eye  through 
an  incidious  inflammation  and  sidcrosis.  As  extraction  with  the 
magnet  is  usually  successful  even  in  these  old  cases,  the  operation  is 
always  performed,  especially  when  there  are  already  signs  of  a  dele- 
terious influence  exerted  by  the  foreign  body.  The  case  is  different 
with  non-magnetic  bodies  in  the  posterior  segment  of  the  eye.  Of  these 
copper  splinters  are  least  well  borne,  and  the  attempt  to  remove  them 
should  be  made  in  every  case.  I  kit  if  such  foreign  body  is  securely 
lodged  without  signs  of  irritation  or  inflammation,  the  operation  should 
be  avoided  on  account  of  its  unfavorable  prognosis,  and  only  under 
taken  if  threatening  phenomena  arise. 


CHAPTER  XX. 

MINOR    CORNEAL    OPERATIONS.      PTERYGIUM.     THE 
OPHTHALMIC  ASSISTANT.     ANESTHESIA. 

THE  OPERATIVE  THERAPY  OF  SERPIGINOUS  ULCER. 

Small  serpiginous  ulcers  may  be  combated  by  subconjunctival 
injections  of  a  i-iooo  corrosive  sublimate  solution,  using  TO"  cc. 
Should  no  further  progress  of  the  ulcer  be  observed  on  the  following 
day  this  treatment  may  be  continued,  but  if  the  infiltration  tends  to 
spread,  the  thermocautery  is  to  be  immediately  employed,  since 
every  millimeter  of  tissue  is  valuable,  as  the  affected  area  is  situated  at 
or  near  the  center  of  the  cornea.  The  cautery  is  applied  to  the  entire 
ulcer,  paying  especial  attention  to  its  yellow,  infiltrated,  progressing 
borders.  A  simultaneous  puncture  of  the  anterior  chamber  has  a 
favorable  influence  on  the  course  of  the  disease,  and  should  therefore 
not  be  neglected  in  view  of  the  insignificance  of  the  procedure.  It  makes 
no  difference  whether  or  not  the  hypopyon  is  thereby  removed  from  the 
eye.  If  the  ulcer  has  penetrated  deeply,  the  opening  of  the  anterior 
chamber  may  be  accomplished  after  first  thoroughly  cauterizing  the 
whole  ulcer  by  burning  through  the  cornea  in  a  punctiform  spot,  so 
that  the  aqueous  humor  trickles  out  slowly.  The  slight  perforation 
soon  closes  and  an  adhesion  of  the  iris  is  not  to  be  feared,  if  the  opening 
is  in  the  region  of  the  pupil. 

Serpiginous  ulcers  that  have  affected  more  than  one-third  of  the 
cornea  are  not  longer  amenable  to  this  form  of  treatment,  as  the  exten- 
sive destruction  of  the  cornea  in  its  whole  thickness  leads  to  perforation 
before  completion  of  the  cauterization,  thus  bringing  this  interference 
to  a  close.  It  is  in  these  cases,  and  only  in  these  cases,  that  we  follow 
another  procedure,  i.e.  splitting  the  cornea  according  to  the  Saemisch 
method.  The  cocainized  eye  is  held  with  the  forceps  below,  and  the 
cornea  is  then  split  in  the  region  of  the  serpiginous  ulcer  with  a  Graefe 
knife.  In  performing  this  operation,  the  knife  with  the  cutting  edge 
directed  forward,  is  introduced  into  the  healthy  part  of  the  cornea  close 
to  one  edge  of  the  ulcer,  and  is  brought  out  at  the  opposite  edge,  so 
that  the  ulcer  is  cut  through.  The  blade  of  the  instrument  must  be 

230 


MINOR    CORNEAL    OPERATIONS.  23! 

rather  parallel  to  the  cornea,  in  order  that  the  lens  will  not  be  injured, 
as  would  occur  if  held  more  perpendicular  and  the  point  thus  directed 
backward.  By  a  slow,  sawing  motion,  the  cornea  is  then  split  in  the 
region  of  the  ulcer  from  behind  forward.  It  is  best  to  direct  the  incision 
so  that  it  passes  through  the  extending,  yellow,  infiltrated  part  of  the 
border.  The  aqueous  humor  escapes  rapidly  through  the  incision, 
and  the  hypopyon  is  frequently  forced  into  the  wound,  whence  it  can 
readily  be  extracted  in  a  compact  mass  by  a  pair  of  forceps. 

The  opening  into  the  anterior  chamber  must  not  be  allowed  to  close 
until  the  ulcer  has  become  clean  and  retrogressive.  The  reopening  of 
the  incision  in  the  succeeding  days  is  not  difficult,  and  may  be 
accomplished  by  slightly  depressing  one  lip  of  the  wround  with  a  spatula. 
The  splitting  of  the  cornea  does  not  always  have  the  desired  effect,  and 
the  serpiginous  ulcer  progresses  further  and  destroys  the  whole  cornea. 
However,  a  favorable  result  usually  follows,  but  the  operation  has  the 
disadvantage  of  causing  extensive  attachments  between  the  cornea 
and  the  iris.  These  adhesions  cannot  be  avoided,  but  we  select  the 
Saemisch  section  only  in  advanced  serpiginous  ulcers  to  preserve  an  eye 
that  would  probably  otherwise  be  entirely  ruined  by  the  infection. 

Before  the  patient  leaves  the  hospital,  a  broad  iridectomy  is  per- 
formed behind  the  transparent  part  of  the  cornea,  to  prevent  the  other- 
wise certain  onset  of  increased  pressure,  which  would  completely  do 
away  with  the  visual  power  and  cause  the  patient  other  inconveniences 
through  the  transformation  of  the  flat  cicatrix  into  a  staphyloma. 
Serpiginous  ulcers  are  frequently  associated  with  purulent  disease  of 
the  lachrymal  canal,  and  an  important  part  of  the  treatment  of  the 
corneal  affection  is  the  immediate  removal  of  the  diseased  sac. 

OPERATION  FOR  PTERYGIUM. 

Transplantation  of  the  pterygium  is  the  simplest  and  at  the  same 
time  the  most  reliable  method.  After  well  cocainizing  the  eye,  the 
lids  are  opened  with  a  spring-speculum,  and  the 
patient  is  told  to  look  toward  the  side  opposite  to 
the  pterygium.  The  operator  then  grasps  the  neck 
of  the  pterygium  with  toothed  forceps,  stretches  it 
somewhat,  and  applies  a  lancet  flat  against  the  Hg.  115.— Trans] .lantu- 

11         i  /    \  /T-"  \          l'on  °f  pterygium. 

cornea  completely  separating  the  head  (a)  (r  ig.  115) 

from  the  corneal  tissue,  with  which  it  is  firmly  united.     This  peeling 

off  must  be  done  carefully,  so  that  none  of  the  advancing  part  of  the 


332  OPHTHALMIC    SURGERY. 

pterygium  is  left  on  the  cornea.     When  the  head  is  once  free,  the 
remaining  loosely  connected  portion  of  the  growth  is  separated  as 
far  as  the  border  of  the  cornea  and  for  a  short  distance  on  to  the 
sclera.     The  border  of  the  pterygium,  lying  at  the  apex  of  the  loosened 
conjunctiva,  is  excised  with  the  scissors,  and  the 
pterygium  with  its  apex  (a)  turned  inward  so  that 
its  raw  surface  is  directed  forward  and  its  two 
borders  (ab,  ac]  diverge  toward  the  cornea  (Fig. 
Fig.  1 1 6.— Transplan-  u6).     By  two  or  three  suitable  sutures  the  borders 

tation  of  ptervgium  su-  .      ,          ,  .  i 

tures  in  pcstion  are  now  united,  taking  care  that  no  wound  re- 

mains at  the  limbus.  The  first  suture  is  therefore 
introduced  vertically  in  the  neighborhood  of  the  limbus,  it  being 
advisable  to  include  with  the  needle  a  few  superficial  fibers  of  the 
sclera  between  the  two  edges.  A  projection  is  formed  on  the  conjunc- 
tiva by  the  transplanted  pterygium,  but  in  a  short  time  it  completely 
disappears. 

Arlt's  method  for  the  removal  of  pterygium  is  also  used  frequently. 
The  pterygium  is  held  with  toothed  forceps  at  its  neck,  where  it  can  be 
slightly  lifted  from  the  underlying  part.  The 
separation  is  the  same  as  previously  described. 
While  none  of  the  advancing  head  should  be 
left  on  the  cornea,  no  normal  corneal  layers 
should  be  unnecessarily  removed  by  cutting  too 
deeply,  as  this  would  produce  a  more  extensive 
scar.  After  separation  of  the  pterygium,  two 
convergent  incisions  (c  b  u,  b  d)  are  made  in  its 
body  (see  Fig.  117).  A  rhomboidal  piece  is 

i  .      j  .     .  ,    ,       i        j          ,  ,.    Fig.  117. — Arlt's  method  of 

thus  excised,  consisting  of  the  head  and  part  of     operation  for  pretygium. 
the  body.     The  conjunctiva  opening  is  accur- 
ately closed  by  two  sutures  which  are  introduced  in  a  vertical  posi- 
tion.    The  wound    in    the  cornea  heals  by  cicatrization,  causing  a 
permanent  opacity.     The  complete  and  accurate  closure  of  the  wound 
in  the  conjunctive  is  of  great  importance,  otherwise  the  conjunctiva 
will  again  be  drawn  on  to  the  cornea  by  the  cicatricial  tissue. 

TATTOOING  THE  CORNEA. 

Only  solid,  flat  scars  of  the  cornea  are  suitable  for  tattooing.  If 
there  is  a  tendency  to  ectasis  or  if  the  scar  is  thinned,  tattooing  is 
to  be  avoided.  India  ink  is  the  only  pigment  applicable  for  the  pur- 


MINOR    CORXEAL    OPERATIONS.  233 

pose.  It  is  introduced  into  the  corneal  scar  by  pricking  either  with  a 
cluster  of  needles,  or  with  a  single,  broad  needle,  provided  with  a 
groove  for  holding  the  coloring  matter.  In  order  to  produce  the 
best  results,  the  tattooing  must  usually  be  done  in  several  sittings. 
Thorough  cocainization  is  always  necessary.  To  hold  the  eye  steady, 
the  conjunctiva  should  be  grasped  with  slightly  roughened  forceps,  as 
toothed  forceps  produce  slight  wounds  which  become  impregnated  with 
the  pigment. 

Tattooing  with  the  cluster  of  needles  is  to  be  preferred  to  that  done 
with  the  grooved  needle.  The  latter  is  better  suited,  however,  for 
accurate  definition  of  the  border.  With  the  cluster  of  needles  which 
are  put  in  vertically,  the  operator  produces  simultaneously  a  series  of 
closely-placed  points,  and,  therefore,  works  more  rapidly.  There  is 
also  less  danger  of  perforating  the  cornea  than  with  the  grooved  needle, 
which  has  to  be  applied  in  a  slanting  direction  to  prevent  perforation. 
If  the  latter  should  accidently  be  produced  and  the  pigment  enters 
the  anterior  chamber,  it  must  be  opened  with  a  lancet  and  washed  out. 

Froehlich's  method  is  an  excellent  procedure  for  imitating  a  beauti- 
ful, round,  black  pupil.  It  is  recommended  for  very  large  and  thick, 
flat  scars.  With  a  v.  Hippel  trephine  a  superficial  furrow  is  cut,  corre- 
sponding in  position  and  size  to  the  pupil  of  the  other  eye.  Then,  with 
a  lancet  applied  on  the  flat,  the  superficial  layers  of  the  cicatrix,  con- 
taining epithelium  and  a  few  lamellae,  are  removed  in  the  form  of  a 
disk.  The  exposed  base  is  scarified  in  all  directions  with  the  cutting 
edge  of  the  lancet  and  the  ink  is  rubbed  in  well.  In  this  way  a  pro- 
nounced and  uniformly  black  pupil  is  produced,  which  closely  resembles 
a  true  pupil.  The  surroundings  are  then  tattooed  by  pricking  with 
the  cluster  of  needles  until  the  desired  shade  is  produced. 

OPERATION  FOR  CORNEAL  STAPHYLOMA. 

The  method  of  Beer-Wecker  is  employed  for  the  removal  of  a 
complete  corneal  staphyloma.  The  conjunctiva  is  detached  completely 
around  the  limbus,  as  in  the  operation  for  enucleation,  is  thoroughly 
undermined,  and  a  purse-string  suture  introduced  which  is  at  first 
left  loose.  The  epithelium  on  the  limbus  and  the  border  of  the  staphy- 
loma is  then  carefully  denuded,  in  order  to  produce  a  raw  surface  to 
which  the  conjunctiva  can  adhere  when  drawn  over  it.  The  staphy- 
loma is  then  cut  away;  in  doing  this  the  lower  half  is  first  separated  by 


234  OPHTHALMIC    SURGERY. 

means  of  a  Gracfe  knife  in  the  same  manner  as  for  a  cataract-operation. 
The  flap  thus  formed  is  held  by  forceps  and  the  upper  half  is  separated 
with  the  scissors.  A  narrow  band  should  be  left  above  and  below, 
through  which  sutures  are  introduced  and  left  loose.  Before  tying  the 
sutures,  the  lens  is  allowed  to  escape  from  the  eye  by  opening  the  lens- 
capsule;  after  which  the  sutures  are  rapidly  drawrn  together  to  avoid  loss 
of  the  vitreous  humor.  Then  the  wound  in  the  conjunctiva  is  closed 
by  drawing  upon  the  purse-string  suture. 

In  a  recent  staphyloma  with  thin  walls  an  attempt  may  be  made 
to  produce  a  flat  scar  by  simply  splitting  the  staphyloma.  In  this 
operation  it  is  best  to  make  a  bow-shaped  incision  like  that  for  cataract, 
so  that  the  flap  is  formed  from  the  wall  of  the  staphyloma.  By  retrac- 
tion of  the  flap,  the  wound  is  made  to  gape,  which  effect  may  be  increased 
by  excising  a  narrow  edge  from  the  flap.  The  lens  is  removed  by  rup- 
ture of  the  anterior  capsule.  Then  by  means  of  a  compress  and  ban- 
dage, a  flat  cicatrix  may  be  produced. 

The  incision  of  a  staphyloma  has  only  one  advantage  over  enuclea- 
tion,  namely,  that  the  patient  is  left  with  a  freely  movable  stump, 
upon  which  an  artificial  eye  can  be  well  fitted.  On  the  other  hand, 
the  operation  has  the  disadvantage  of  not  guarding  against  sympathetic 
ophthalmia.  It  is,  therefore,  evident  that  enucleation  should  be 
preferred  in  all  cases  in  which  there  is  suspicion  of  sympathetic  oph- 
thalmia or  in  which  the  latter  may  readily  develop. 

EXPRESSION  OF  TRACHOMA-GRANULES. 

This  operation  is  performed  under  cocain-anesthesia.  After  repeated 
instillation  of  the  cocain-solution  into  the  conjunctival  sac,  a  sub-con- 
junctival  injection  of  a  i  per  cent,  cocain-solution  is  made  beneath  that 
part  of  the  conjunctiva  upon  which  the  expression  is  to  be  commenced. 
The  conjunctiva  over  the  granules  is  then  superficially  scarified 
with  a  Graefe  knife,  so  that  the  granules  may  readily  make  their  exit 
through  the  slight  incisions  thus  produced.  In  order  to  gain  comfort- 
able access  to  the  upper  fold,  the  lid  is  everted.  Moreover,  the  sub- 
conjunctival  injection  causes  a  marked  swelling  and  protrusion  of  the 
fold.  For  expression  of  the  granulations  we  employ  either  Knapp's 
roller-forceps  or  Kuhnt's  expresser. 

In  using  Knapp's  roller-forceps,  the  conjunctival  fold  is  grasped 
between  the  two  branches,  one  end  of  the  roller-forceps  being  introduced 


MINOR    CORXEAL    OPERATIONS.  235 

above  between  the  scleral  conjunctiva  and  that  of  the  lid,  while  the 
other  end  is  placed  upon  the  anterior  surface  of  the  tarsus.  The 
instrument  is  pressed  together  rather  forcibly  and  is  drawn  slowly 
along  the  conjunctiva.  During  this  procedure  the  ridged  rollers  pass 
over  the  conjunctiva  and  express  the  granulations.  The  traction 
should  not  be  made  rapidly,  as  this  may  produce  more  marked  lesions 
of  the  conjunctiva  in  the  form  of  lacerations,  and  give  rise  to  fresh 
scar-formation.  The  more  carefully  the  operation  is  done,  the  less 
painful  will  it  be  and  less  injurious  to  the  conjunctiva.  The  consider- 
able bleeding  which  follows  is  combated  by  active  sponging  with  a 
weak  bichlorid-solution. 

In  a  similar  manner  the  lower  lid  is  freed  of  its  granulations.  With 
Knapp's  roller  it  is  more  difficult  to  strip  the  semi  unar  fold,  and  especi- 
ally to  squeeze  out  isolated  granulations,  without  including  and  com- 
pressing the  surrounding  conjunctiva.  For  these  cases  it  is  best  to 
employ  simply  a  small  forceps,  the  narrow  branches  of  which  can  readily 
grasp  and  express  isolated  granulations.  If  a  group  of  granulations 
is  found  on  a  sharply  circumscribed  area  of  the  upper  fold  or  elsewrhere, 
we  usually  excise  this  part  of  the  conjunctiva.  On  the  other  hand, 
we  prefer  the  method  of  expression  in  those  cases  in  which  the  granular 
formation,  though  sharply  circumscribed,  includes  the  whole  length 
of  the  fold.  In  order  to  extract  the  granulations  from  the  tarsal  con- 
junctiva, the  tarsus  itself  must  be  seized  between  the  branches  of  the 
roller-forceps. 

With  Kuhnt's  expressor  the  granulations  are  pressed  out  of  the 
conjunctiva  without  pulling  on  the  latter.  The  advantage  of  this  " 
instrument,  therefore,  lies  in  the  avoidance  of  the  lesions  which  occasion- 
ally follow^  laceration  of  the  conjunctiva.  Kuhnt  recommends  the 
instrument  especially  for  advanced,  felty  trachoma,  as  in  these  cases  tin- 
conjunctiva  of  the  transitional  fold  is  easily  lacerated  and  wounded  by 
the  rolling,  on  account  of  the  felty  change.  The  unpleasant  result  of 
this  injury  would  be  a  marked  contraction  of  the  conjunctival  sac. 
With  Kuhnt's  expressor  all  pulling  and  lacerating  of  the  conjunctiva 
is  avoided,  and  the  granulations  are  pressed  out  of  their  beds  like 
comedones. 

After  expression,  cold  compresses  should  be  applied  diligently 
for  several  hours.  After  an  interval  of  about  two  days,  the  further 
medical  treatment  of  the  conjunctival  disease  may  be  commenced,  i.e., 
touching  with  2  per  cent,  silver-nitrate  solution. 


236  OPHTHALMIC    SURGERY. 

THE  OPHTHALMIC  ASSISTANT. 

In  order  to  obtain  free  access  to  the  eye  with  the  instruments  during 
operations,  the  lids  must  be  adequately  opened.  In  those  operations 
in  which  the  eyeball  is  not  cut  into  or  is  incised  only  to  a  slight  extent, 
we  employ  the  spring-speculum.  It  is,  therefore,  used  in  strabismus- 
operations,  in  pterygium-operations,  discissions,  puncture  of  the 
anterior  chamber,  etc.  On  the  other  hand,  we  dispense  with  the  use 
of  the  speculum  in  iridectomy  for  glaucoma  and  in  cataract-operations. 
Even  those  operators  who  regularly  use  the  lid-speculum  designate 
it  as  "  an  instrument  dangerous  to  the  eye, but  indispensable"  (Terrien). 
The  first  attribute  is  correct,  but  not  the  second.  The  lid-speculum 
will  cause  no  injury  in  a  patient  who  is  quiet  and  who  does  not  twitch, 
especially  if  the  assistant  holds  it  carefully  in  his  hand  and  directs  it  so 
that  there  is  no  pressure  exerted  on  the  eye.  In  any  case,  the  lid- 
speculum  often  becomes  a  great  hindrance;  indeed,  with  a  small  palpe- 
bral  fissure  it  may  render  impossible,  for  example,  an  upward  incision. 
The  injury  produced  by  introduction  of  the  lid-speculum  may  even 
amount  to  a  catastrophe  if  the  patient  strains,  the  wound  begins  to 
gape,  and  the  vitreous  humor  presents  itself.  In  addition,  it  may 
then  become  very  difficult  to  free  the  lids  from  the  instrument.  In 
Mueller's  lid-speculum,  the  branches  are  turned  around  by  closure  of 
the  speculum  so  that  the  lids  free  themselves.  If  the  operator  can 
command  the  services  of  even  a  half-experienced  assistant,  this  is 
certainly  to  be  preferred  over  the  lid-speculum.  . 

The  work  of  the  assistant  consists  in  separating  the  lids  and 
holding  the  palpebral  fissure  open  only  during  the  short  periods  that 
the  operator  works  on  the  eye.  In  the  intervals,  while  the  instruments 
are  being  changed,  the  eye  washed  out,  etc.,  the  lids  are  released  so 
that  they  cover  the  eye. 

In  opening  the  palpebral  fissure  (see  p.  125),  the  assistant  applies 
the  thumb  of  the  right  hand  to  the  edge  of  the  superior  lid, 
raising  it  and  at  the  same  time  pushes  the  lower  lid  down  with  a  finger 
of  the  left  hand  laid  on  its  edge.  The  upper  lid  is  at  the  same  time 
somewhat  drawn  away  from  the  globe,  so  that  its  border  does  not 
get  into  the  wound  if  the  eye  should  be  suddenly  rotated  upward  or  if 
the  lid  should  suddenly  slip.  The  lower  lid  should  be  pushed  down- 
ward in  such  manner  that  it  does  not  roll  outward.  The  extent  of 
separation  of  the  lids  depends  upon  the  operative  procedure  to  be 
undertaken. 


MINOR    CORXEAL    OPERATIONS.  237 

The  work  of  the  assistant  during  a  cataract-operation  may  be 
detailed  as  follows:  During  the  incision,  the  palpebral  fissure  is  held 
open  as  just  described.  When  the  operator  has  completed  the  incision, 
the  assistant  lets  the  upper  lid  slide  down,  in  such  a  manner  that  it 
does  not  make  the  wound  gape.  It  must,  therefore,  be  brought  down 
at  a  certain  distance  from  the  cornea  in  the  sagittal  plane.  This  is 
best  accomplished  by  drawing  the  external  canthus  somewhat  down- 
ward, whereby  the  upper  lid  performs  the  desired  movement.  The 
lower  lid  must  not  be  released  until  the  upper  lid  covers  the  wound. 

In  performing  the  iridectomy  the  palpebral  fissure  is  opened  in  the 
same  way,  and  the  assistant  need  only  see  that  the  finger  which  holds 
the  upper  lid  is  not  placed  in  the  way  of  the  operator  (see  Fig.  60  of 


Fig.  118. — Assistance.  The  operator  grasps  the  upper  lid  by  its  cilia,  draws  it  slightly 
away  from  the  eyeball,  and  guides  it  downward  over  the  wound,  while  the  spoon  is  inserted 
under  the  lid  to  keep  it  away  from  the  surface  of  the  globe. 

the  cataract-operation,  p.  125).  As  the  operator  must  introduce 
the  forceps  into  the  wound  from  above,  the  assistant  places  his  finger 
on  the  lid  either  internally  or  externally. 

In  opening  the  anterior  capsule,  the  operator  himself  raises  the 
upper  lid  with  the  left  hand.  The  assistant  holds  the  lower  lid  with 
one  hand,  and  at  the  same  time  takes  a  Daviel  spoon  in  the  other  hand, 
which  is  held  against  the  border  of  the  upper  lid.  If  the  lid  should 
slip  through  the  fault  of  the  operator  or  from  the  twitching  of  the 
patient,  it  will  fall  upon  the  spoon,  and  will  thus  slide  over  the  wound 
without  turning  the  latter  back.  At  the  critical  moment  the  operator 
can  help  himself  without  much  chance  of  failure,  by  slipping  the 
rapidly  closed  capsule  forceps  under  the  upper  lid  and  thus  drawing 
it  down.  Fig.  118  shows  how  the  operator  himself  may  draw  down  the 


238  OPHTHALMIC    SURGERY. 

lid  by  its  cilia,  while  the  spoon  in  the  assistant's  hand  is  ready  to 
slip  under  the  lid  and  hold  it  away  from  the  eye. 

Control  of  the  lower  lid  always  requires  great  care.  Even  though 
the  patient  twitches  but  slightly,  the  lower  lid  should  never  remain 
without  fixation  after  the  upper  lid  is  raised.  If  the  lower  lid  is  left 
free,  and  the  patient  makes  it  tense  through  innervation  of  the  palpebral 
muscle,  the  lid  will  be  pressed  against  the  globe  and  will  cause  the 
wound  to  gape  and  open.  The  vitreous  humor  may  even  be  expressed 
in  this  way. 

If  the  operator  contemplates  removing  the  lens  in  its  capsule, 
on  account  of  thickening  of  the  latter,  he  should  allow  the  assistant  to 
hold  both  lids,  so  that  he  himself  may  take  in  his  left  hand  the  spatula 
with  which  the  scleral  edge  of  the  wound  is  somewhat  depressed  to 
favor  the  escape  of  the  lens. 

During  expression  of  the  cataract  the  operator,  while  raising  the 
upper  lid  with  either  hand  performs  writh  the  lower  lid  the  massage- 
movements  that  have  been  described  for  expressing  the  lens.  The 
assistant  holds  the  Daviel  spoon,  prepared  to  introduce  it  under  the 
upper  lid,  if  necessary,  and  to  extract  the  lens  when  it  protrudes  to  the 
extent  of  one-half.  In  performing  this  latter  act,  the  spoon  is  placed 
against  the  equator  of  the  lens  and  thus  lifts  it  out. 

During  reposition  of  the  iris  the  operator  raises  the  upper  lid 
and  the  assistant  holds  the  lower.  If  the  patients  are  quiet  and  do 
not  twitch,  the  assistant's  task  is  an  easy  one.  Of  course,  the  assistant 
must  never  press  the  lids  against  the  eye.  In  protruding  eyes  the 
opening  of  the  lids  requires  special  care.  The  lids  must  not  be  pushed 
far  backward,  but  must  be  opened  merely  enough  for  the  requirements 
of  the  operator.  The  work  of  the  assistant  is  much  more  difficult 
in  the  case  of  a  patient  who  strains.  But  it  is  just  in  such  cases  that 
the  value  of  a  good  assistant  is  fully  appreciated.  Skillful  separation 
of  the  lids  in  the  correct  manner  and  at  the  right  time  often  prevents 
the  otherwise  certain  prolapse  of  the  vitreous  humor. 

In  unruly  patients  it  may  be  quite  impossible  to  proceed  in  the 
manner  described.  The  upper  lid  must  then  be  elevated  by  inserting 
a  Desmarres  elevator.  All  pressure  on  the  eye,  however,  must  be 
carefully  avoided.  This  elevator  is  permitted  to  remain  in  place 
during  the  whole  operation,  while  the  lower  lid  must  also  be  fixed  at 
the  same  time,  for  reasons  that  have  been  mentioned.  The  only 
disadvantage  of  the  elevator  is  that  it  stands  in  the  way  of  instruments 


MINOR    CORXEAL    OPERATIONS.  239 

that  are  to  be  introduced  from  above.  The  spring-speculum,  however, 
must  never  be  used  in  restless  patients. 

If  a  prolapse  of  the  vitreous  occurs,  the  lids  must  not  be  aimlessly 
released,  as  is  often  done  by  frightened  assistants.  On  the  contrary, 
the  upper  lid  still  firmly  held  must  be  cautiously  lowered  over  the 
gaping  wound,  while  the  operator  inserts  under  the  lid  for  its  guidance 
the  instrument  which  he  happens  to  have  in  his  hand.  This  may  be  a 
closed  pair  of  Wecker's  scissors,  the  capsule-forceps,  the  spatula,  the 
spoon,  or  even  the  handle  of  the  Graefe  knife.  The  lower  lid  may  be 
released  by  the  assistant  only  after  the  upper  lid  has  covered  the 
wound.  Otherwise  the  patient  will  raise  the  flap  still  further  with 
his  lower  lid,  and  will  thus  express  the  vitreous.  In  patients  who  are 
known  beforehand  to  be  restless  and  likely  to  twitch,  the  opening  of 
the  lids  may  be  materially  facilitated  by  performing  an  extensive 
canthotomy  immediately  before  the  operation. 

Occasionally  it  may  also  fall  to  the  lot  of  the  assistant  to  hold  the 
eye  with  fixation-forceps.  As  repeatedly  stated,  fixation  is  only 
employed  in  cataract-operation  while  making  the  incision.  In  non- 
congested  and  well-cocainized  eyes,  the  iridectomy  is  usually  accom- 
panied by  so  little  pain  that  the  patients  are  perfectly  quiet  during  its 
performance.  After  opening  the  eyeball  by  a  long  incision,  the  use  of 
fixation-forceps,  even  with  the  greatest  care,  causes  a  gaping  of  the 
wound.  The  fixation-forceps  should  only  be  employed  when  abso- 
lutely necessary.  Especially  in  the  cataract-operation  their  use  can 
only  be  forced  by  unreasonable  patients.  In  such  cases  the  assistant 
applies  the  forceps  to  the  limbus  exactly  at  the  lower  edge  of  the  cornea, 
and  draws  the  eye  slightly  down.  The  forceps  also  keep  the  lower 
lid  away  from  the  globe.  The  iridectomy  may  under  these  circum- 
stances become  difficult. 

If  the  upper  lid  is  held  up  by  the  Daviel  spoon,  the  eyeball  must 
be  carefully  drawn  downward  a  little  with  the  forceps;  otherwise,  it- 
may  be  impossible  in  the  small  space  to  draw  out  the  iris  with  the 
forceps.  On  the  other  hand  it  may  be  easier  to  slip  into  the  anterior 
chamber  from  the  side  with  a  properly  bent,  blunt  tenaculum,  and 
thus  draw  out  and  excise  a  fold  of  iris  from  the  pupillary  border.  Like- 
wise the  opening  of  the  anterior  lens-capsule  must  then  be  performed 
with  a  sharp  tenaculum  that  has  been  bent  in  the  required  direction. 
The  otherwise  painful  excision  of  the  iris  in  inflammatory  glaucoma, 
injuries,  prolapse  of  the  iris,  etc.,  may  be  rendered  considerably  less 


240  OPHTHALMIC    SURGERY. 

painful  by  dropping  a  little  cocain-solution  on  the  exposed  iris  after  the 
anterior  chamber  is  opened.  However,  in  certain  cases  the  eye  must 
be  held  with  the  forceps  in  order  to  be  quite  safe,  and  this  we  do  almost 
regularly  in  excision  of  a  prolapsed  iris  in  an  inflamed  eye.  During 
reposition  of  the  iris  it  may  be  necessary  to  draw  the  eye  downward 
with  the  forceps,  because  the  patient  will  not  voluntarily  look  down. 
In  this  case  it  is  best  for  the  operator  himself  to  hold  the  eye  in  the 
required  position. 

As  already  mentioned,  the  eye  must  be  held  fast  in  all  procedures 
with  cutting  or  puncturing  instruments,  e.g.,  during  the  incision, 
during  discission,  etc.  Occasionally  an  exception  can  be  made  in 
very  quiet  patients  who  will  turn  their  eyes  in  the  required  direction. 
For  example,  if  the  conjunctiva  tears  away  during  the  incision,  and  if 
the  patient  looks  in  the  right  direction,  there  is  no  objection  to  com- 
pleting the  incision  without  further  fixation.  A  discission,  the  incision 
in  a  linear  extraction,  or  a  puncture  may  exceptionally  be  performed 
without  fixation. 

Beside  proper  fixation,  the  position  of  the  operator's  fingers  is 
important.  The  support  of  the  operator's  hand  must  also  be  at  a 
safe  point.  For  this  purpose,  the  fourth  finger  of  the  hands  usually 
rests  in  a  suitable  position  on  the  head  of  the  patient.  In  incisions 
from  the  external  side  the  operator's  hand  is  supported  on  the  temple 
or  malar  bone.  In  incisions  from  below,  the  hand  is  supported  on  the 
cheek;  and  in  incisions  from  above,  on  the  forehead.  The  operator  is 
not  then  taken  unaware  by  an  unexpected  movement  of  the  patient's 
head.  The  incision  directed  downward  is  the  more  readily  accom- 
plished because  every  patient  shows  a  tendency  to  avoid  the  instru- 
ment by  an  upward  movement  of  the  eye,  and  it  is  usually  much  easier 
to  look  upward  than  downward. 

It  was,  therefore,  repeatedly  recommended  to  perform  all  ophthalmic 
operations,  including  cataract-extraction,  by  the  inferior  incision, 
and  in  fact,  special  methods  were  devised  for  this  purpose,  but,  as 
iridectomy  must  be  performed  in  most  cases,  operators  soon  adhered 
to  the  upward  cut.  In  fact,  in  the  establishment  of  a  broad  coloboma 
for  glaucoma,  it  is  of  importance  that  the  coloboma  be  covered  by  the 
upper  lid.  The  lower  operations  are  therefore  limited  to  those  cases 
in  which  it  is  known  beforehand  that  a  coloboma  will  not  be  necessary, 
such  as  puncture  of  the  cornea,  linear  extraction  and  similar  opera- 
tions. There  are,  however,  certain  cases  which  are  especially  suitable 


MINOR    CORXEAL    OPERATIONS.  241 

for  the  inferior  operation.  In  cataract-patients  an  accompanying 
ptosis  may  cause  the  pupillary  region  to  be  covered  by  the  upper  lid,  an 
amyotrophic  ptosis  being  not  uncommon  in  old  persons.  This  is  an 
indication  for  the  inferior  operation  with  a  narrow  coloboma,  avoiding 
the  periphery  of  the  iris. 

Auxiliary  minor  assistance  may  be  serviceable  during  an  opera- 
tion. It  is  the  duty  of  the  assistant  to  remove  the  blood  from  the  con- 
junctival  sac  by  sponging.  The  sponges  should  be  kept  in  sterilized, 
physiologic  saline  solution.  The  sponge  is  well  squeezed  out  and  one 
end  is  formed  into  a  point.  This  end  is  inserted  into  the  internal 
angle  of  the  eye  so  that  it  absorbs  the  blood  from  the  point  outward; 
or  the  end  may  be  drawn  from  the  internal  angle  outward  along  the 
inferior  transitional  fold,  taking  the  blood  with  it.  Direct  sponging 
of  the  operation-wound  in  the  eye  is  to  be  avoided  as  much  as  possible. 
With  marked  hemorrhage  into  the  anterior  chamber  it  will  serve  the 
purpose  very  well  if  the  assistant  strokes  the  blood  out  of  the  anterior 
chamber,  while  the  operator  stands  ready  with  the  instrument  to 
perform  rapidly  the  next  operation  (iridectomy  or  opening  of  the 
capsule)  as  soon  as  he  can  obtain  a  clear  view  of  the  chamber. 

If  necessary,  the  assistant  should  turn  the  conjunctival  flap  back 
with  a  spatula,  in  case  it  should  get  in  the  way  of  the  operator.  He 
should  stroke  the  iris  back  into  its  place,  if,  during  an  extraction 
without  iridectomy,  the  border  of  the  pupil  should  become  stretched 
against  the  lens  as  it  makes  its  exit.  Occasionally  it  may  be  necessary 
for  the  assistant  to  cut  off  the  iris  with  the  deWecker  scissors,  if 
the  operator,  for  example,  in  the  excision  of  a  prolapsed  iris,  holds  and 
directs  the  eye  with  one  hand  while  the  other  hand  draws  out  the  iris. 

ANESTHESIA. 

In  all  ophthalmic  operations  there  is  an  advantage  in  being  able  to 
operate  under  local  anesthesia.  \\e  use  it  on  the  most  extensive 
scale,  and  endeavor  to  make  it  suffice  wherever  possible  in  the  place  of 
general  anesthesia.  In  most  operations  on  the  eyeball  itself,  the 
co-operation  of  the  patient  in  bringing  the  eye  into  the  proper  position 
will  make  the  procedure  much  less  difficult  and  will  render  unnecessary 
the  dangerous  fixation  of  the  eye  during  many  operations.  General 
anesthesia  not  only  robs  us  of  this  factor,  which  is  important  for  the 
faultless  accomplishment  of  many  operations,  but  also  draws  in  its 
train  another  series  of  baneful  influences  which  are  important  in 

16 


242  OPHTHALMIC   SURGERY. 

patients  subjected  to  any  eye  operation.  Among  these  latter  may  be 
mentioned  the  dulled  consciousness,  the  restlessness  of  the  patient 
upon  awakening,  the  often  violent  vomiting,  etc. 

General  anesthesia  is  therefore  confined  to  the  following  cases: 

1.  Children  who  do  not  as  yet  possess  sufficient  intelligence  to  keep 
quiet  and  conduct  themselves  sensibly. 

2.  More  extensive  operations  in  the  orbit  and  on  the  lids,  especially 
if  the  parts  subjected  to  operation  are  sensitive  on  account  of  inflam- 
matory conditions,  such  as  exenteration,  enucleation  of  inflamed  eyes, 
more  extensive  plastic  operations  and  similar  procedures. 

3.  Severe  operations  on  the  eye  itself,  if  local  anesthesia  is  refused 
(especially  in  inflammatory  glaucoma,  excision  of  prolapsed  iris  in 
marked  inflammatory  conditions,  etc.)  or  if  the  patient  is  not  suitable 
for  local  anesthesia  on  account  of  other  circumstances,  such  a  pro- 
nounced blepharospasm,  dementia,  great  irritability,  etc. 

Cocain-anesthesia  in  operations  on  the  eye  itself  is  usually  effected 
by  a  3  per  cent,  solution,  which  is  dropped  into  the  eye  several  times 
during  a  period  of  ten  minutes.  The  eye  must  be  kept  closed  during 
this  process  of  cocainization.  If  it  remains  open,  the  cocain  may 
readily  produce  a  dryness  of  the  cornea  with  epithelial  changes,  which 
may  not  only  impede  the  operation  on  account  of  cloudiness  of  the 
cornea,  but  may  also  cause  the  patient  pain  after  the  operation.  If 
the  eye  is  injected,  a  few  drops  of  adrenalin-solution  should  be 
instilled  in  the  eye.  The  last  application  should  be  made  just  before 
the  operation,  as  the  constriction  of  the  vessels  caused  by  the  adrenalin 
soon  disappears  and  is  replaced  by  a  vascular  relaxation  which  might 
cause  considerable  bleeding  during  the  operation. 

The  advantages  of  cocain  surpass  those  of  all  its  substitutes.  Its 
constricting  influence  on  the  vessels  is  an  excellent  property,  which 
is  of  great  value  in  every  operation.  The  dilatation  of  the  pupil  which 
it  causes  is  undesirable  only  in  glaucoma-operations,  but  can  usually 
be  prevented  by  a  preceding  instillation  of  eserin.  Recently  we  have 
substituted  for  cocain  in  these  cases  a  3  per  cent,  solution  of  alypin, 
which  must  be  supplemented  by  adrenalin,  as  it  does  not  possess  any 
vaso -constrictor  properties.  We  also  prefer  alypin  for  sounding,  for 
extraction  of  foreign  bodies  from  the  surface  of  the  cornea,  etc.,  as  it 
does  not  cause  the  patient  the  inconvenience  of  pupillary  dilatation. 

To  produce  a  more  profound  anesthesia  of  the  deeper  parts  of  the 
eye,  we  drop  some  cocain-solution  into  the  anterior  chamber 


MINOR    CORNEAL    OPERATIONS.  243 

after  it  is  opened  in  cases  in  which  manipulation  of  the  iris  will  pre- 
sumably be  painful,  as  in  inflamed  eyes.  For  this  purpose  only  a 
sterilized  solution  can  be  used.  For  operations  on  the  lids  a  sub- 
cutaneous injection  of  a  i  per  cent,  cocain-solution  will  usually 
suffice.  The  injected  fluid  must  be  suitably  distributed  throughout 
the  field  of  operation. 

The  addition  of  adrenalin  (3  to  5  drops)  to  the  cocain-solution 
will  reduce  the  bleeding  to  a  minimum.  More  accurate  directions 
have  been  given  with  the  various  operations,  so  that  the  best  effect 
can  be  produced  with  the  least  quantities.  Aimless  injection  in  one 
place  with  neglect  of  other  parts  of  the  operative  field  will  not  produce 
the  desired  result.  The  dose  of  cocain  which  we  employ  in  most 
operations  is  a  minimal  one,  amounting  at  most  to  one  Pravaz  syringe- 
ful  (o.oi  gm.  cocain),  so  that  poisoning  need  not  be  feared  in  the 
most  sensitive  individuals.  Only  in  enucleation  is  as  much  as  0.03 
gram  allotted,  a  quantity  which  is  also  far  below  the  maximum  dose. 

In  place  of  general  chloroform  or  ether  narcosis,  the  general  anes- 
thesia with  scopolamin  and  morphin  is  recommended,  carried  out 
according  to  the  following  prescription.  These  solutions  should  be 
freshly  prepared  each  time: 

9 

Scopolamin.  hydrobromat,  o.oi 

Aq.  destillat  30  .o 
9 

Morphin.  hydrochlr.,  0.075 

Aq.  destillat  9.0 

Three  hours  before  the  operation  one  cc  of  each  solution  is 
injected  under  the  skin  of  the  upper  arm,  first  injecting  one  solution, 
and  then,  without  withdrawing  the  needle,  making  the  other  injection 
in  the  same  place,  but  in  another  direction.  Even  after  these  injections 
the  patient  will  become  somnolent,  quiet  and  so  insensible  of  pain 
that  the  operation  can  often  be  performed  in  this  stage  with  the  aid 
of  simultaneous  cocainization  of  the  eye.  But  if  the  desired  effect 
is  not  obtained,  the  same  dose  of  each  solution  must  again  be  injected 
fifteen  minutes  before  the  operation.  Thereupon  the  patient  can  be 
subjected  to  the  operation  in  a  completely  relaxed  condition,  if  at  the 
same  time  the  eye  is  made  insensible  by  cocain.  The  advantage  of 
this  method  is  that  the  patient  sleeps  quietly  for  several  hours  after 


244  OPHTHALMIC   SURGERY. 

the  operation,  does  not  vomit  and  exhibits  no  restlessness  upon  awaken- 
ing. Moreover,  after  carrying  out  these  methods,  a  general  narcosis 
can  be  rapidly  produced  by  a  few  drops  of  ether  or  chloroform. 

Bandaging  After  Operations  on  the  Eye. — We  employ  Fuchs' 
lattice  in  men,  and  Snellen's  cup  in  women,  the  cup  being  attached  by 
strips  of  adhesive.  The  latter  is  not  advisable  for  men,  because  the 
plaster  will  not  adhere  to  the  bearded  skin.  In  children  and  restless 
patients  bandages  are  applied,  and  with  the  aid  of  starch  a  stiff  dress- 
ing is  produced,  which  will  also  sufficiently  protect  the  eye  against 
careless  contact.  The  application  of  pressure-bandages  has  been 
described  in  connection  with  the  operations  in  which  they  are  indicated. 


INDEX. 


Accidents  during  anterior  sclerotomy,  195 
cataract  extraction,  140 
cataract  expression,  146 
discission,  160 

iridectomy  for  glaucoma,  187 
trephining  of  cornea,  216 
Accumulation  of  blood  after  excision  of 

lachrymal  sac,  13 
Acute  dacryocystitis,  20 

iritis,  puncture  of  cornea  in,  206 
Adrenalin,  242 

in  cyclodialysis,  201 
in  enucleation,  103 
in  operations  upon  lachrymal  appa- 
ratus, 15 

in  probing  of  lachrymo-nasal  duct,  29 
Adults,    young,    linear    extraction    for 

cataract  in,  164 

Advancement  of  extraocular  muscles,  86 
after-treatment,  91 
contraindication,  92 
dressing,  91 

fixation  of  muscle  to  limbus,  91 
incision,  86 

means  of  influencing  effect  of,  96 
stretching  of  muscle,  87 
sutures,  87 
of  rectus  internus,  indications  for, 

101 
Advantages  of  capsule-forceps  in  opening 

anterior  lens-capsule,  134 
Fuchs's  method  of  tarsorrhaphy,  68 
Graefe     knife     in    iridectomy    for 

glaucoma,  184 
lancet  in   iridectomy  of  glaucoma, 

184 
After-results  of  anesthesia-hemostasis  of 

lachrymal  apparatus,  16 
After-treatment  of  advancement  of  extra- 
ocular  muscles,  91 
conjunctivoplasty,  213 
corneal  transplantation,  217 
excision  of  iris,  210 
expression  of  trachoma  granules,  235 


in 


After-treatment  of  Hess's  operation  for 

ptosis,  74 

Saemisch  section,  231 
simple  extraction,  157 
Age  limit  for  muscle-operations,  102 
Air-bubbles    in    anterior    chamber 

extraction,  153 
Alypin,  242 

as  corneal  anesthetic,  168 
in  iridectomy  for  glaucoma,  184 
Anatomy  of  lachrymal  sac,  i 
AnePs  syringe,  28 

Anesthesia    in    advancement    of    extra- 
ocular  muscles,  86 
enucleation,  103,  107 
Hess's  operation  for  ptosis,  75 
of  lachrymal  apparatus,  15 
lachrymo-nasal  duct,  28 
ophthalmic  surgery,  241 
optico-ciliary  neurotomy,  112 
tenotomy  of  rectus  internus,  85 
Angle  at  which  lancet  is  held  in  making 
incision  in  iridectomy  for  glau- 
coma, 181 

Anterior  lachrymal  crest,  i,  17 
lens-capsule,  incision  of,  159 

opening,  131 
sclerotomy,  193 

accidents  during,  195 
faulty  position  of  incision,  195 
indications,  196 
intralamellar  incision  in,  195 
iridodialysis  in,  196 
results  of,  196 

synechia  following  cataract  extrac- 
tion, 142 

operations  for,  219 
Apparatus,  lachrymal,  i 
Appearance  of  vitreous  prior  to  removal 

of  lens  in  extraction,  149 
Applicability  of  strabismus  operation,  92 
Application  of  iridotomy,  170 
Aqueous,    escape   of,    during   discission 

through  cornea,  161 
Arlt's  median  tarsorrhaphy,  70 
operation  for  pterygium,  232 


245 


246 


INDEX. 


Assistance,  auxiliary  minor,  241 
Assistant,  duties  of  ophthalmic,  236 

in  extraction  without  iridectomy,  157 
Astigmatism   following  cataract   extrac- 
tion, 141 

Atrophic  iris  in  glaucoma,  188 
Atropin  after  excision  of  iris,  210 
Attached  iris  in  glaucoma,  liberation  of, 

190 
Auxiliary  minor  assistance,  241 

B 

Backward  luxation  of  lens  during  extrac- 
tion, 155 
Ball,   introduction  of  glass  or  gold,   in 

eye,  in 
Bandage,  binocular,  139 

in  conjunctivoplasty,  213 
corneal  transplantation,  217 
iridotomy,  171 

Bandaging  after  operations,  244 
Beer-Wecker  operation  for  corneal  staph- 

yloma,  233 
Best    method    of    operating    in    total 

symblepharon,  122 
Bilateral  ectropion,  52 
Binocular  handage  after  extraction,  139 
Black  cataract,  146 
Blood,  accumulation  of,  after  excision  of 

lachrymal  sac,  13 
Blunt  hook  in  iridectomy  for  glaucoma, 

188 
Bodies,  foreign,  in  the  eye-ball,  extraction 

of,  222 

enucleation  for,  229 
other  than  iron,  228 
in  vitreous,  removal  by  posterior 

sclerotomy,  199 

Bowman's  operation  of  discission,  169 
slitting  the  canaliculus,  26 
probes,  27 

Buediner's  operation,  117 
Bulging  of  vitreous  as  an  indication  of 
prolapse,  153 


Canaliculus,  dilatation  of,  24 

slitting  of,  26 

Canthal  ligament,  internal,  4 
Canthoplasty,  61 

indications  for,  62 

Kuhnt's  method,  63 

sutures  in,  62 

technic  62 

Canthotomy,  63,  113 
Capsule-forceps,  131 


Capsule,  lens,  wound  of,  210 

opening  of,    in   extraction   without 

iridectomy,  157 

Capsulotomy  in  secondary  cataract,  1 70 
Care  of  iris  in  linear  extraction  of  soft 

cataract,  177 
Cataract,  black,  146 

in  children,  discission  for,  163 
congenital,  discission  for,  163 
expression  of,  134,  146 
extraction  of  senile,  124 
accidents  during,  140 
backward  luxation  of  lens,  155 
collapse  of  cornea,  155 
complications  of,  140 
explosive  hemorrhage  in,  155 
hemorrhage  attending,  141 
incision,  127 
without  iridectomy,  156 
following  iridectomy  for  glaucoma, 

191 

knife,  Graefe,  127 
operations,  124,  159 
partial,  discission  for,  163 
secondary,  operations  for,  159,  169 

discission  in,  169 
soft,  linear  extraction  for,  174 
Causes    of    difficulty    in    expression    of 

cataract,  145 

penetrating  wounds  of  eye-ball,  226 
prolapse  of  vitreous  during  extrac- 
tion, 148 

secondary  glaucoma,  207 
turning  down  of  corneal  flap  after 

extraction,  154 
Cavity,  orbital,  exenteration  of,  112 

opening  of,  17 

Changing  of  dressing  in  enucleation,  107 
in  excision  of  lachrymal  sac,  13 
in  operation  for  cicatricial  ectropion, 

57 
Children,  muscle-operations  in,  102 

new-born,  probing  in,  29 
Chloroform,  243 
Chorioid,  prolapse  of,  in  scleral  wounds, 

214 

Chronic  epiphora,  30 
Crystalline  lens,  backward  luxation  of, 

155 

operations,  124 

subluxation,  in  iridectomy  for  glau- 
coma, 191 

Cicatricial  ectropion,  52 
operation  for, 
dressing,  56 
insertion  of  sutures,  53 


INDEX. 


247 


Cicatricial  ectropion,  results,  54 
skin-grafts  in,  55 
technic,  52 
Cicatrix    in    cases    of    foreign    body    in 

eyeball,  222 
Cilia  forceps,  41 
Ciliary  body,     prolapse    of,     in    scleral 

wounds,  214 

Closure,  complete,  of  palpebral  fissure,  69 
of    the  wound    after    advancement 

of  extraocular  muscles,  90 
after  enucleation,  107 
Everbusch's  operation  for  ptosis,  80 
tenotomy  of  rectus  internus,  84 
Cocain-anesthesia,  242 
Cocain   in  advancement  of  extraocular 

muscles,  86 
enucleation,  103,  107 
iridectomy  for  glaucoma,  188 
operations  upon  the  lachrymal  appa- 
ratus, 15 

probing  lachrymo-nasal  duct,  28 
tenotomy,  85 

Coloboma  in  optical  iridectomy,  165 
Collapse     of     cornea     during     cataract 

extraction,  155 

eye-ball  due  to  fluid  vitreous,  154 
Combination  of  Dieffenbach's  and  Bue- 

diner's  operation,  117 
Combined  discission,  170 
Comparative  value  of  several  operations 

for  ptosis,  82 

Complete  closure  of  palpebral  fissure,  69 
symblepharon,  121 

Rogman's  operation,  121 

unpedicled  flap  operation,  123 

operations,  dressing,  123 
Complications  of  anterior  sclerotomy,  195 
cataract  extraction,  140 
cyclodialysis,  202 
discission,  160 

discission  through  sclera,  172,  174 
enucleation,  108 
excision  of  iris,  210 
excision  of  lachrymal  sac,  17 
expression  of  cataract,  146 
Graefe's  operation  for  senile  entro- 

pion,  60 

Hotz-Anagnostakis  operation,  35 
iridectomy  in  cataract  extraction,  144 
for  glaucoma,  187 

in  secondary  glaucoma,  207 
iridotomy,  171 
Kuhnt-Szymanowski    operation    for 

senile  ectropin,  51 
linear  extraction  for  soft  cataract,  177 


Complications  of  operations  for  cicatricial 

ectropion.  54 

for  secondary  cataract,  169 
reposition  of  iris  in  iridectomy  for 

glaucoma,  189 
tenotomy,  101 

Congenital  cataract,  discission  for,  163 
Conical  probe,  24 
Conjunctiva,  laceration  of,  in  iridectomy 

for  glaucoma,  187 
suturing  of,  in  cyclodialysis,  202 
tearing  of,  during  cataract  extraction, 

140 
transplantation    of,     De    Wecker's 

method  of,  214 

Conjunctival  flap  in  conjunctivoplasty,2i2 
in  corneal  transplantation,  217 
in  extraction  operation,  129 
position  of,  after  extraction,  139 
suture  after  advancement  of  extra  - 

ocular  muscles,  90 
Conjunctivoplasty,  212 
after-treatment,  213 
indications  for,  212 
Contingencies  in  expression  of  cataract, 

146 

Contraindication  to  advancement,  92 
for  Everbusch's  operation  for  ptosis, 

81 

for  Hess's  operation  for  ptosis,  76 
for  probing  lachrymo-nasal  duct,  31 
Convergent   strabismus,    indications   for 

operations  in,  98 
Cornea,    collapse    of,     during    cataract 

extraction,  155 
discission  through,  159 
infection  of,  following  cataract  ex- 
traction, 142 
paracentesis  of,  205 
splitting  of,  230 
tattooing  of,  168,  232 
trephining  of,  for  anterior  synechia, 

219 
Corneal  erosion  in  excision  of  lachrymal 

sac,  13 

operations,  minor,  230 
staphyloma,  operations  for,  233 
transplantation,  216 
partial,  217 
total,  218 

Von  Hippel's  218 
trephine,  216 
of  Von  Hippel,  218 
ulcers,  230 

corneal  puncture  in,  206 
wound  in  excision  of  iris,  210 


248 


INDEX. 


Cortical  substance,  removal  of,  in  extrac- 
tion without  iridectomy,  157 

Crest,  anterior  lachrymal,  i 

Counteracting  sutures  in  tenotomy,  95 
indications  for,  100 

Counter-puncture    in    extraction    opera- 
tion, 127 

Crest,  anterior  lachrymal,  17 

Crucial  incision  in  opening  anterior  lens- 
capsule,  161 

Cup-bandage,  Snellen's  244 

Curette,   Daviel's,   in  foreign  bodies  in 
eyeball,  227 

Curettement  in  excision  of  lachrymal  sac, 
12 

Cyclodialysis  (Heine),  199 
complications  of,  202 
dressing  in,  202 
indications  for,  203 
results  of,  203 

Cystic  scars  after  iridectomy  for  glau- 
coma, 221 

Cyst    of    iris    as    cause    of    secondary 
glaucoma,  207 

Cystotome,  131 

D 

Dacryocystitis,  20 

Dangers  of  excision  of  iris,  209 

probing  of  lachrymo-nasal  duct,  27 
trephining   of    cornea    for   anterior 

synechia,  220 
Daviel's  spoon  in  expression  of  cataract- 

ous  lens,  136 
in  foreign  bodies,  227 
Deep  fascia  in  excision  of  lachrymal  sac,  4 
Deepening  of  the  anterior  chamber  as  a 
sign  of  prolapse  of  vitreous,  153 
Descemet's  membrane,  detachment  of,  in 

cyclodialysis,  202 
Desmarres'  elevator,  238 

spoon,  152 
Detachment   of   Descemet's   membrane 

in  cyclodialysis,  202 
retina,  posterior  sclerotomy  for,  198 
following  prolapse  of  vitreous,  155 
conjunctiva  in  enucleation,  103 
Details  of  cyclodialysis,  199 

incision  for  cataract  extraction,  127 
incision  in  iridectomy  for  glaucoma, 

180 
De  Wecker's  method  of  transplantation 

of  the  conjunctiva,  214 
pince-ciseaux,  129 
Diagnosis  of  foreign  bodies  in  eye-ball. 


Dieffenbach's  operation  on  eyelids,  115 

results  of,  117 

Difficulties   attending    anterior    sclerot- 
omy, 194 
enucleation,  108 
excision  of  lachrymal  sac,  17 
expressing  cataractous  lens,  146 
iridectomy  for  secondary  glau- 
coma, 207 
linear  extraction   of    soft    cataract, 

177 

Dilaceration  of  secondary  cataract,  169 
Dilatation  of  the    canaliculus,  24 

lachrymal  sac,  20 
Diminution  of  vision  in  foreign  bodies  in 

eye-ball,  222 

Direction  of  lachrymal  canaliculus,  24 
Directions  for  making  incision  in  cataract 

extraction,  142 

opening  capsule  in  cataract  extrac- 
tion, 145 
Disadvantages  of  Beer-Wecker  operation 

for  corneal  staphyloma,  234 
extraction  without  iridectomy,  156 
Fuchs's  method  of  tarsorrhaphy,  68 
lancet  in  incision  in  iridectomy  for 

'glaucoma,  185 

Panas's  operation  for  trichiasis,  38 
precorneal  iridotomy,  165 
Discission,  159 

accidents  during,  160 

Bowman's  169 

combined,  170 

for  congenital  cataract,  163 

through  cornea,  159 

for  high  myopia,  162 

indications     for,     in     high     grade 

myopia,  162 
needles,  159 
for  partial  cataract,  163 
prolapse  of  vitreous  in,  162 
through  sclera,  complication,  174 
through   sclera  in  secondary   cata- 
ract, 172 

in  secondary  cataract,  169 
for  totally  opaque  lenses,  163 
of  a  transparent  lens,  161 
with  two  needles,  169 
Disk,  Fritsch's  movable  stenopaeic,  167 
Dislocation  of  lens,  effects  of,  in  extrac- 
tion, 147 
Dissection  in  Everbusch's  operation  for 

ptosis,  77 

Hess's  operation  for  ptosis,  71 
lachrymal  structures,  2 
Distichiasis,  operations  for,  32 


IXDEX. 


249 


Divergent    strabismus,     indications    for 
operations  in,  99 

Division  of  muscles  in  enucleation,  104, 

105,  107 

optic  nerve  in  enucleation,  106 
straight  eye-muscles  in  enucleation, 
104 

Dose  of  cocain,  243 

Double  tenaculum,  Reisinger's,  150,  151 

Douching  of  lachrymal  sac,  28 

Drainage  in  incision  of  lachrymal  sac,  13 

Dressing  after  operations,  244 

in    advancement    of    extraocular 

muscle,  91 

conjunctivoplasty,  213 
cyclodialysis,  202 

Dieff  enbach-Buediner  operation ,  1 1 8 
enucleation,  107 
excision  of  lachrymal  gland,  24 
excision  of  lachrymal  sac,  13 
extraction,  139 

Hess's  operation  for  ptosis,  73 
Hotz-Anagnostakis  operation,  35 
iridotomy,  117 

Kuhnt-Szymanowski  operation,  50 
linear  extraction  of  soft  cataract,  177 
operation  for  cicatricial  ectropion,  56 
operations  for  total  symblepharon, 
123 

Ducts,  lachrymal,  7 

lachrymo-nasal,  probing  of,  27 

Duties  of  ophthalmic  assistant,  157,  236 


Ectasia  of  sclera  as  cause  of  secondary 

glaucoma,  207 
as  contraindication  of  advancement, 

92 

Ectropion,  42 
bilateral,  52 
cicatricial,  52 
following  excision  of  lachrymal  sac, 

20 

of  lower  lid,  26 
operations  for,  42 
paralytic,  52 
senile,  43 
spastic,  42 
Effects   of  adhesions   in   optical    iridec- 

tomy,  1 68 

dislocation  of  lens  in  extraction,  147 
failure  to  open  lens-capsule,  147 
produced  by  advancement  of  rectus 

externus,  96 

Electrolytic  epilation  in  trichiasis,  41 
Elevator,  Desmarres',  238 


Employment  of  capsule-forceps  in  open- 
ing capsule,  145 
Entropion,  58 

operations  for,  58 
senile,  59 
spastic,  58 
Enucleation,  103 

complications  of,  108 
detachment  of  conjunctiva  in,  103 
division  of  straight  eye-muscles  in, 

104 

division  of  vertical  muscles,  105 
dressing  in,  107 
for  foreign  bodies,  229 
in  glaucoma,  192 
indications  for,  no 
insertion  of  scissors,  105 
in    prolapse    of    ciliary    body    and 

chorioid,  214 

resection  of  optic  nerve  in,  1 10 
severance  of  optic  nerve,  106 
Epilation  in  trichiasis,  41 
Epiphora,  chronic,  30 
Erosion   of   the    cornea   in    excision   of 

lachrymal  sac,  13 
Escape    of    aqueous    during    discission 

through  cornea,  161 
Eserin  in  iridectomy  for  glaucoma,  184 

after  simple  extraction,  157 
Ether,  243 

Everbusch's  operation  for  ptosis,  77 
closure  of  the  wound,  80 
contraindications,  81 
indications,  77 
result  of,  80 
sutures,  78 
Eversion  of  inferior  lachrymal  puncture, 

26 
of    lid    in    excision    of    palpebral 

lachrymal  gland,  22 
Evisceration  of  the  eye-ball,  in 
Examination  in  cases  of  foreign  body  in 

eye -ball,  222 

Excision  of  corneal  cicatrix,  216 
iris,  209 

in  iridectomy  for  glaucoma,  185 
after  prolapse,  indications,  215 

time  for,  215 
lachrymal  sac,  i 

incomplete,  14,  18 
palpebral  lachrymal  gland.  22 
portion  of  lid  for  senile  ectropion,  44 
prolapsed   iris  after  simple  extrac- 
tion, 158 

in  optical  iridectomy,  165 
for  senile  entropion,  59 


2^0 


INDEX. 


Excision    of    tarsus    in     Kuhnt-Szyma- 

nowski  operation,  46 
Exenteration  of  orbital  cavity,  113 

indications  for,  113 

Exophthalmos  following  tenotomy,  101 
Expression  of  cataract,  134,  146 

trachoma  granules,  234 
Expressor,  Kuhnt's,  235 
Expulsive   hemorrhage   in   cataract   ex- 
traction, 155 

in  iridectomy  for  glaucoma,  190 
Extensive  ruptures  of  eye,  operation  in, 

no 

synechia,  iridectomy  in,  211 
Extent  of  effect  produced  by  advance- 
ment of  rectus  externus,  96 
External  rectus,  tenotomy  of,  86,  96 

tarsorrhaphy,  65 
Extirpation  of  lachrymal  sac,  i 

palpebral  lachrymal  gland,  22 
Extraction    of    cataractous    lens    in   its 

capsule,  150 
foreign  bodies  from  the  interior  of 

the  eye,  222 
through  an  opening  in  the  sclera, 

227 

other  than  iron,  228 
iron  splinters  by  magnet  operation, 

224 

linear,  for  soft  cataract,  174 
senile  cataract,  124 
accidents,  140 

anterior  synechia  following,  142 
astigmatism  in,  141 
black  cataract,  146 
collapse  of  cornea,  155 
complications,  140 
counter-puncture,  127 
Daviel's  spoon,  136 
dressing,  139 
duties  of  assistant,  237 
expression  of  lens,  134,  146 
expulsive  hemorrhage,  155 
faulty  incision,  140 
gaping  of  wound,  141 
hemorrhage  attending,  141 
hemorrhage  after  iridectomy,  144 
incision,  127 

infection  of  cornea  following,  142 
intralamellar  incision.  143 
iridectomy  in,  129 
iridodialysis  in,  144 
length  of  incision,  142 
luxation  of  lens,  147 
luxation  backward  of  lens,  155 
massage  after  extraction,  137 


Extraction  of  senile  cataract,  accidents 
opening  of  anterior    lens-cap- 
sule, 131,  145 
position  of  conjunctiva!  flap  after, 

J39 

prolapse  of  vitreous,  148 
reposition  of  iris  after,  138 
technic  of,  124 
toilet  of  eye  after,  138 
without  iridectomy,  156 
Eye,  extraction  of  foreign  bodies  from 

interior  of,  222 
toilet  of,  after  extraction,  138 
Eye-ball,  collapse  of,  due  to  fluid  vitreous, 

154 

foreign  bodes  in,  prognosis  of,  227 
enucleation  of,  103 
Evisceration  of,  in 
Mules's  operation,  in 
optico-ciliary  neurotomy    operation, 

112 

penetrating  wounds  of,  226 
summary  of  wounds  of,  226 
Eyelids,  operations  on,  32 

plastic     operations,     Dieffenbach's, 

US 
plastic  operations,  Dieffenbach-Bue- 

diner's,  117 
plastic     operations     with     pedicled 

flaps,  115 

plastic  operations  on,  Fricke's,  115 
Eye-muscles,  operations  on,  84 


Factors,  influencing  length  of  incision  in 

senile  cataract,  142 
Failure  to  open  lens-capsule,  effects  of, 

M7 

False  passage  in  probing  lachrymo- 
nasal  duct,  27 

Fascia,  in  excision  of  lachrymal  sac,  3,  n 
tarso-orbital,  23 

Faulty  incision  in  cataract  extraction,  140 
position  of  incision  in  anterior 
sclerotomy,  195 

Firm  bandage  after  iridotomy,  171 

First  method  of  operating  for  anterior 

synechia,  221 

step  in   Kuhnt-Szymanowski   oper- 
ation, 44 

Fistula  following  excision  of  lachrymal 

sac,  19 
lachrymal,  30 

Fixation  forceps  used  in  cataract  extrac- 
tion, 124 
of  muscle  to  the  limbus,  91 


INDEX. 


251 


Fixing-suture  in  Fuchs's  method  of  tar- 

sorrhaphy,  67 
Flap,  conjunctival,  in  conjunctivoplasty, 

212 

in  corneal  transplantation,  217 
in  extraction  operation,  129,  139 
Flaps,  pedicled,  in  eye-lid  operations,  115 
skin-graft,  in  operation  for  cica- 
tricial  ectropion,  55 
Flarer's  operation  for  trichiasis,  38 
Fluid  vitreous,  154 
Forceps,  capsule,  131 

fixation,  used  in  cataract  extraction, 

124 

iris,  129 

Knapp's  roller,  234 
Foreign  bodies  in  eye-ball,  diagnosis  of, 

222 
extraction  of,   from  the  interior  of 

the  eye,  222 
extraction    through   an    opening  in 

sclera,  227 
enucleation,  229 
other  than  iron,  228 
prognosis  of,  227 
in  vitreous,  removal  by  posterior  scle- 

rotomy,  199 
Fourth     step     in     Kuhnt-Szymanowski 

operation,  48 

Fricke's  operation  on  eye-lids,  115 
Fritsch's  movable  stenopaeic  disk,  167 
Froehlich's    method    of    tattooing    the 

cornea,  233 

Fuchs's  keratoplasty,  216 
lattice  bandage,  244 
method  of  tarsorrhaphy,  65 
advantage,  68 

disadvantage  of,  68 

sutures  in,  67 

preliminary    treatment    in    patients 
subject  to  hemorrhage,  155 


Gaping  of  wound  in  cataract  extraction, 

141 

as  a  sign  of  prolapse  of  vitreous,  154 
Gaillard's  suture  for  spastic  entropion,  58 
General  anesthesia  in  ophthalmic  oper- 
ations, 242 
Gland,  palpebral  lachrymal,  excision  of, 

22 

Glass  ball  in  eye,  introduction  of,  in 
Glaucoma,  180 

anterior   sclerotomy    (De    Wecker), 

193 
atrophic  iris  in,  188 


Glaucoma,  cyclodialysis  in,  203 
enucleation  in,  192 
iridectomy  for,  180 
cataract  following,  191 
cystic  scars  after,  221 
expulsive  hemorrhage  in,  190 
Graefe  knife  in,  184 
indications  for,  187 
spontaneous  rupture  of  lens-capsule 

in.  191 

subluxation  of  lens  in,  191 
liberation  of  attached  iris  in,  190 
posterior  sclerotomy,  196 
secondary,  iridectomy  in,  206 
secondary,  operations  for,  205 
time  for  operation  in,  189 
Gold  ball  in  eye,  introduction  of,  in 
Graefe  knife,  127 

in  anterior  sclerotomy,  193 

Beer-Wecker  operation  for  corneal 

staphyloma,  234 
iridectomy  for  glaucoma,  184 
operations  anterior  synechia,  221 
operation  for  secondary  cataract, 

170 

posterior  sclerotomy,  196 
Saemisch  section,  230 
transfixion    for  seclusion   of    the 

pupil,  208 
Graefe's  operation  for  senile  entropion, 

?9 

incision,  59 
results,  60 
Granules,  trachoma,  expression  of,  234 

H 

Haab's  large  magnet,  224 

Hand  used  in  making  incision  in  cataract 

extraction,  144 
Heine's  cyclodialysis,  199 
Hemorrhage  after  iridotomy,  171 

after  division  of  optic  nerve,  no 
attending  cataract  extraction,  141 
during  iridectomy  in  cataract  extrac- 
tion, 144 

during  iridectomy  for  glaucoma,  189 
expulsive,  in  cataract  extraction,  155 
expulsive,    in    iridectomy   for   glau- 
coma, 190 
following  prolapse  of  vitreous,  1 54 

in  cyclodialysis,  201 
Hemostasis  of  lachrymal  apparatus,  15 
Hernia  lentis,  191 

of  vitreous,  153 
Hess's  operation  for  ptosis,  71 
after  treatment.  74 


INDEX. 


Ness's  anesthesia,  75 

contraindications  for,  76 

dissection,  71 

dressing  in,  73 

incision,  71 

indications,  75 

results,  75 

sutures  in,  71 
High  myopia,  indications  for  discission 

in,  162 

Hollow  probes,  30 
Hook,  blunt,  in  iridectomy  for  glaucoma, 

188 

Hooks  in  excision  of  lachrymal  sac,  12 
Horizontal  incision  in  iridotomy,  172 

sutures  in  operation  for  cicatricial 

ectropion,  53 
Hotz-Anagnostakis  operation,  32 

complications  of,  35 

dressing  in,  35 

incision,  32 

results,  36 

sutures  in,  34 

technic  of,  32 


Ideal  indication  for  optical  iridectomy, 

1 66 
Importance  of  Graefe  knife  in  iridectomy 

for  glaucoma,  184 
Improper  position  of  incision  in  anterior 

sclerotomy,  195 
Incision  in  advancement  of  extraocular 

muscles,  86 

of  anterior  lens-capsule,  159 
in  anterior  sclerotomy  (DeWecker's), 

193 
in  capsule  of  Tenon  as  an  adjunct 

to  tenotomy,  94 
in  cyclodialysis  (Heine),  199 
in  Everbusch's  operation  for  ptosis, 

77 

for   extirpation  of  lachrymal  sac,  2 
in    extraction    of    senile    cataract, 

127 

for  foreign  bodies,  228 
with  the  Graefe  knife  in  iridectomy 

for  glaucoma,  184 
Graefe's  operation  for  senile  entro- 

pion,  59 

in  Hess's  operation  for  ptosis,  71 
in  Hotz-Anagnostakis  operation  for 

ptosis,  32 

inferior,  in  cataract-extraction,  240 
intermarginal,     in      Kuhnt-Szyma- 

nowski  operation,  46 


in 


Incision,  intralamellar,  in  anterior  scie- 

rotomy,  194,  195 
intralamellar,  in  cataract  extraction, 

143 

intralamellar,  in  iridectomy  for  glau- 
coma, 185,  187 

for  iridectomy  in  glaucoma,  180 

in  iridotomy,  171 

with  lancet  in  iridectomy  for  glau- 
coma, 185 

in  linear  extraction  for  soft  cataracts, 

174 

length  of,  in  cataract  extraction,  142 
in  operation  for  cicatricial  ectropion, 

52 

in  optical  iridectomy,  165 
in  Panas's  operation  for  trichiasis,  36 
in  paracentesis  of  cornea,  205 
in  posterior  sclerotomy,  197 
in  simple  extraction,  157 
in  tarsorrhaphy,  66 
Incomplete  excision  of  lachrymal  sac,  18 

results  of,  14 

Incorrect  position  of  incision  in  iridec- 
tomy for  glaucoma,  187 
India  ink  in  tattooing  of  cornea,  232 
Indications  for  advancement   of  •  rectus 

internus,  101 
anterior  sclerotomy,  196 
canthoplasty,  62 
conjunctivoplasty,  212,  213 
counteracting  suture,  100 
cyclodialysis,  203 

discission  in  high-grade  myopia,  162 
discission  through  sclera,  172 
enucleation,  no 

Everbusch's  operation  for  ptosis,  77 
excision  of  iris,  209 

after  prolapse,  215 
exenteration  of  orbital  cavity,  113 
extraction  without  iridectomy,  156 
Graefe     knife     in    iridectomy    for 

glaucoma,  184 
iridectomy  in  glaucoma,  187 
iridotomy,  170 

Kuhnt's  method  of  canthoplasty,  63 
operation  in  convergent  strabismus, 

98 
for  divergent  strabismus,  99 

in  secondary  glaucoma,  205 
optical  iridectomy,  164 
optico-ciliary  neurotomy,  112 
posterior  sclerotomy,  198 
probing  lachrymo-nasal  duct,  27,  29 
prolapse  of  vitreous,  152 
ptosis  operation,  75 


Indication-    for    roection    of    lachrymal 

sac.  jo 

slitting  lachrvmal  cana'iculus.  2(1 
supporting:  suuiri1.   100 
tarsorrhaphy.  65.  oX 
Infection    of    cornea    follo,viiiL,r    cataract 

extraction.    142 
Inferior    inci.-ion    in    cataract-extraction, 

240 

lachrymal  puncture,  cversioti  of.  _;0 
Influence  of  small  wound  in  expres.-ion  of 

cataract.    140 
Injection  of  cocain  in  cnuclcalion.  707 

<>f  cocain  volution   into   the  anu-rior 

chamber.  242 
subcon  junctival.      in       serpi.^inous 

ulcer.  2^0 
injury  to   lachrymal   canaliculus  during 

dilatation.  25 

lachrymal  sac  during  excision,   17 
to  lens  during  iridectomy  for  t^lau 

coma.   1X7 

to  lens  in  trephining  the  cornea.  220 
to  the  lens-capsule  in  iridectomy  for 

glaucoma,    i  SS 

Ink.  India,  in  tattooing  of  cornea,  2^2 
Insertion  of  an  unpedicled   tlap  without 
incision  in   total  symhlepharon, 


scissors  m  enuclcation.   105 
sutures    in    advancement    of    extra- 
ocular  muscles.  Sj 
Kvcrbusch's  operation    for  ptosis, 

7-s 
(iraefc's  operation  for  senile  en 

tropion.  60 

I  less's  operation  for  ptosis,  71 
I  lot/.-. \naLmostakis  operalion.   ^2 
operation  for  cicatricial  ec  tropion. 

53 
Instruments  for  iridectomy  in  extraction, 

I2t, 

extraction.   127 
Interior    of    eye.    extraction    of    foreign 

bodies  from.  222 
Intermanrinal  incision  in    Kuhnt-S/.yma- 

nowski  operation.  4^1 
in  tarsorrhaphv.  06 
Internal  canthal  ligament.  4 
palpeliral   ligament,    i 
rectus.  indications  for  advancement 
of.   1 01 


Internal  rectus.  tenotomy  of.  >>4 

tarsorrliapliy,  (xt 
Intralamellar  incision  in  anterior  >clen> 

tolliy.     K;4.     K;5 

cataract  extraction.    14^ 
iriilectomy  lor  glaucoma.   iN>.   \^~ 
Introduction  of  Ljla.-o  or  LTold  liall>  in  eye. 

i  i  i 

knife-needle  in  discission.    i>(; 
l'ai,ren>techer's    sutun-s    for    pb»i>. 

70 
suture>  in   I;uchs's  meth.od  ,  i|  tarsor- 

rhaphy.  07 
\\"elier's   loop.    I  50 
Iridectomy    after     prolapse,     indication.- 

for.  215 

dutie>  of  assistant  in.  -'^7 
glaucoma.    iSo 
I'ataract  folIowin.Lr.    K;I 
cocain  in.    i  SS 
complications  of.  i  ti~ 
complications    during    reposition    oi 

iris.    i<S<; 

disadvantages  of  lancet.    1X5 
excision  of  iris  in.   1X5 
expulsive  hemorrhage  in.  K^O 
( iraefe  knife  in.    184 
hemorrhage  duriiiLT.  iS<; 
inci>ion  tor.   iSo 
indications  for.   1X7 
intralamellar  incision.    1X5 
lancet  in.   i  So 
operation      lor    cystic    >car>    alter. 

22  I 

pain  during.   iSS 

prolapse  of  vitreous  in.   i  go 

repi  isilion  of  iris  in.   i  So 

spontaneous   ruture  of  lens-cap>ule 
i  'i ' 

suhluxation  of  lens.    \<>\ 

ser| n'd nous  ulcer.  2^  i 

in  cataract  extraction,    i  21; 

ci  implicalic  in>  oi.    i  |  j 

exten-ivc  svne(  hia.   2  i  i 

sccondarv  Lrlaui  i  >ma.   Jof> 

complications  of.   207 

oplical.    104 

preliminary.   15'' 
Iridodialysis  in  anterior  srlerolomy,  KjC) 

duriii'j;  iridectomy  in  cataract  extrac 
lion.    14  | 

!<  iv  planet  ima.    i  Sj 
Iridotomy  in  secondary  cataract.    170 

applic  atii  >n  <>\ .    i  70 

precorncal.    10; 
Iris,  atrophic.  in  u'laucoma.   i  SS 


254 


INDEX. 


Iris,  attached  in  glaucoma,  liberation  of, 

190 
care  of,  in  linear  extraction   of  soft 

cataract,  177 
cyst   of,    as  a  cause   of    secondary 

glaucoma,  207 
excision  of,  209 
forceps,  129 

in  iridectomy  for  glaucoma,  185 
operations  on,  164 
prolapse,  after  simple  extraction,  158 
prolapse  of,  conjunctivoplasty  in,  212 
in   extraction  without  iridectomy, 

156 

operation  for,  209 
reposition  of,  after  extraction,  138 
in  iridectomy  for  glaucoma,  186 
scissors,  129 

time  for  excision  after  prolapse,  215 
transfixion    of,    in    iridectomy    for 

glaucoma,  187 

Iritis,  acute,  corneal  puncture  in,  206 
Iron  splinters  in  eye,  224 

J 

Jaesche-Arlt  operation,  39 

K 

Keratitis  profunda,  corneal  puncture,  in, 

206 

Keratoplasty,  216 
partial,  217 
total,  218 

Knapp's  roller  forceps,  234 
Knife,  Graefe  cataract,  127 
in  anterior  sclerotomy,  193 
iridectomy  for  glaucoma,  184 
operations  for  anterior  synechia, 

221 

posterior  sclerotomy,  196 
Saemisch  section,  230 
transfixion  for  seclusion  of  pupil, 

208 

Weber's  27 
Knots  in  sutures  in  excision  of  lachrymal 

sac,  13 

Kuhnt's  conjunctivoplasty,  212 
expressor,  235 
method  of  canthoplasty,  63 
operation  for  senile  ectropion,  44 
Miiller's  modification  of,  52 
Kuhnt-Szymanowski  operation  for  senile 

ectropion,  44 
complications  of,  51 
dressing,  50 
ectropion,  results  of,  51 
technic,  44 


Laceration  of  conjunctiva  in  iridectomy 

for  glaucoma,  187 
Lachrymal  apparatus,  i 
anesthesia  of,  15 
hemostasia  of,  15 
canaliculus,  dilatation  of,  24 
dilatation  of,  injury  during,  25 
slitting  of,  26 
crest,  anterior,  i,  17 
ducts,  7 
fistula,  30 

gland,  palpebral,  excision  of,  22 
sac,  anatomy  of,  i 

acute  inflammation  of,  20 
dissection,  2 
douching  of,  28 
excision  of,  i 
complications,  17 
difficulties  in,  17 
ectropion  following,  20 
fistula  following,  19 
incomplete,  14,  18 
indications  for,  20 
injury  of  sac  during,  17 
persistent  suppuration  after,  18 
ultimate  result,  21 
great  dilatation  of,  20 
tuberculous  disease,  20 
passages,  test  for  permeability  of,  30 
probing,  24 

punctum,  inferior,  eversion  of,  26 
Lachrymo-nasal  duct,  probing  of,  27 
contraindications,  31 
indications  for,  29 
in  new-born,  29 
Lamp,  Sach's,  229 

Lancet  in  iridectomy  for  glaucoma,    180 
Large  magnet,  Haab's,  224 
Last  step  in  Kuhnt-Szymanowski  oper 

ation,  49 

Lattice  bandage,  Fuchs's,  244 
Length  of  incision  in  cataract  extraction, 

142 

for  excision  of  lachrymal  sac,  2 
in  anterior  sclerotomy,  194 
Lens-capsule,  anterior,  incision  of,   131, 

159 

effects  of  failure  to  open,  147 
spontaneous  rupture  in  iridectomy 

for  glaucoma,  191 
Lens,  backward  luxation  of,  155 

discission  for  totally  opaque,  163 

transparent,  161 

expression  of  cataractous,  134,  146 


INDEX. 


255 


Lens,    injury  to,  during  iridectomy  for 

glaucoma,  187 
in  trephining  cornea,  220 
luxation  of,  affecting  expression  in 

cataract  extraction,  147 
operations,  124  • 
removal    of,    in    extraction    of   soft 

cataract,  176 

shrunken,  in  children,  164 
subluxation    of,    in    iridectomy    for 

glaucoma,  191 

swelling  of,  corneal  puncture  in,  206 
wound  of  capsule,  in  excision  of  iris, 

210 

Lentis,  hernia,  191 
Liberation  of  attached  iris  in  glaucoma, 

190 
Lid,   excision  of  portion  of,   for  senile 

ectropion,  44 
lower,  ectropion,  26 
shortening  of,  for  senile  ectropion,  44 
operations  on,  32 
speculum,  236 
Ligament,  internal  canthal,  4 

palpebral,  i 
Linear  extraction,  169 
for  soft  cataract,  174 
for  total  cataract  in  young  adults,  164 
Local  anesthesia  in  ophthalmic  operations, 

241 

Loop,  Weber's,  150 
Lower  lid,  ectropion,  26 

operations  on,  for  trichiasis,  38 
spastic  ectropion  of,  42 
Luxation  of  lens  as  cause  of  secondary 

glaucoma,  207 
effects  of,  in  extraction,  147 

M 

Magnet,  Haab's  large,  224 
operation,  224 
small,  in  foreign  bodies  in  eye-ball, 

226 
Malignant  growths  of  eye,  operation  for, 

in,  113 

Manifestations  of  prolapse  of  vitreous,  153 
Manner  of  making  incision  in  cataract 

extraction    142 
Massage  after  expression  of  cataractous 

lens,  137 
Means  of  determining  whether  optical 

iridectomy  wTill  improve  vision, 

167 

influencing  effect  of  advancement,  96 
Membrane,  Descemet's,  detachment   of, 

in  cyclodialysis,  202 


Median  tarsorrhaphy  (V.  Arlt),  70 
Method,  De  Wecker's,  of  transplantation 
of  the  conjunctiva,  214 

of  Dieffenbach,  115 

for  extirpation  of  lachrymal  sac,  i 

Flarer's,  38 

Fricke's,  115 

Froehlich's,  of  tattooing  the  cornea, 

233 

Fuchs's,  of  tarsorrhaphy,  65 
Hotz-Anagnostakis,  32 
inserting   Graefe    cataract-knife   in 

extraction,  127 

Reisinger's  double  tenaculum,  151 
scissors  in  enucleation,  105 
introducing  Weber's  loop,  150 
Jaesche-Arlt,  39 
Kuhnt's,  of  canthoplasty,  63 
Motais',  for  ptosis,  83 
of  operating  for  anterior  synechia, 

221 

Panas's,  for  ptosis,  83 
for  trichiasis,  36 
of  procedure  when  capsule  of  lens  is 

thickened,  in  extraction,  145 
Rogman's,  121 

Von  Hippel's  of  keratoplasty,  218 
Minor  assistance,  auxiliary,  241 

corneal  operations,  230 
Misplacement    of    incision    in    anterior 

sclerotomy,  195 

Motais'  operation  for  ptosis,  83 
Movable  stenopaeic  disk,  Fritsch's,  167 
Mueller's  lid  speculum,  236 
Mules's  operation,  in 
Miiller's  modification  of  Kuhnt's  oper- 
ation, 52 

tear -sac  speculum,  3 
Muscles  in  excision  of  lachrymal  sac,  3 
Muscle-operations  in  children,  102 
Muscles,  operations  on,  84 
Myopia,  indications  for  discission,  162 

N 

Naso-lachrymal  duct,  probing  of,  27 
Needles,  discission  with  two,  169 
in  excision  of  lachrymal  sac,  12 
in  tattooing  the  cornea,  233 
Nerve,  optic,  resection  of,  in  enucleation, 

no 

Neurotomy,  optico-ciliary,  112 
New-born  children,  probing  in,  29 

O 

Object  of  precorneal  iridotomy,  165 
tarsorrhaphy,  65 


256 


INDEX. 


Opening  anterior  lens-capsule,  in  extrac- 
tion, 131,  145  _ 
duties  of  assistant  in,  237 
in  extraction  without  iridectomy,  157 
linear  extraction  for  soft  cataract, 

175 

of  orbital  cavity,  17 
Operations,  advancement.  86 
anesthesia  in,  241 

anterior  sclerotomy  in  glaucoma,  193 
anterior  synechia,  219 
Arlt's  for  pterygium,  232 
bandaging  after,  244 
Beer-Wecker,  for  corneal    staphy 

loma,  233 

bilateral  ectropion,  52 
Bowman's  discission,  169 
canthoplasty,  61 

canthoplasty,  Kuhnt's  method,  63 
canthotomy,  63 
cataract,  124 
linear  extraction  for,  174 
chrystalline  lens,  124 
complete  closure  of  palpebral  fissure, 

69 

symblepharon,  121 
Rogman's,  121 

cicatricial  ectropion,  52 

congenital  cataract,  163 

conjunctivoplasty,  212 

convergent   strabismus,    indications 
for,  98 

corneal  staphyloma,  233 

corneal  transplantation,  216 

cyclodialysis  (Heine),  199 

cystic    scars    after    iridectomy    for 
glaucoma,  221 

detachment  of  retina,  198 

De  Wecker's  anterior  sclerotomy  in 
glaucoma,  193 

De  Wecker's  method  of  transplan- 
tation of  the  conjunctiva,  214 

Dieffenbach-Buediner,  117 

discission,  159 

discission  through  sclera,  172 

divergent  strabismus,  indications  for, 

99 

dressing  after,  244 
ectropion,  42 
entropion,  58 
enucleation,  103 
for  foreign,  bodies,  229 
in  glaucoma,  192 
Everbusch's,  for  ptosis,  77 
evisceration  of  the  eyeball,  in 
excision  of  iris,  209 


Operations,  exenterationof  orbital  cavity, 

"3 

expression    of    trachoma    granules, 

234 

extraction    of   foreign    bodies    from 
interior  of  the  eye,  222 

other  than  iron,  228 

through  an  opening  in  the  sclera. 
227 

of  lens  in  its  capsule,  150 

senile  cataract,  124 

without  iridectomy,  157 
eyelids,  32 

plastic,  Dieffenbach's,  115 

Dieffenbach-Buediner,  117 

Fricke's,  115 

with  pedicled  flaps,  115 
eye-muscles,  84 
Flarer's,  for  trichiasis,  38 
Fuchs's  method  of  tarsorrhaphy,  65 
glaucoma,  180 

time,  189 

Graefe's,  for  senile  entropion,  59 
Haab  large  magnet,  224 
Heine's,  199 
Hess's  for  ptosis.  71 
Hotz-Anagnostakis,  32 
incision    of    anterior    lens-capsule, 

159 

internal  tarsorrhaphy,  69 
iridectomy  in  extraction,  129 
for  glaucoma,  180 
iridotomy  linear  extraction,  169 
keratoplasty,  216 
Kuhnt's  conjunctivoplasty,  212 
Kuhnt's,   Miiller's  modification,  of, 

52 

Kuhnt's,  for  senile  ectropion,  44 

lengthening  palpebral  fissure,  61 

liberation  of  attached  iris  in  glau- 
coma, 190 

linear  extraction  for  soft,  174 

lower  eyelid  for  trichiasis,  38 

magnet,  224 

median  tarsorrhaphy,  70 

minor  corneal,  230 

Motais',  for  ptosis,  83 

Mules's,  in 

muscle,  simultaneous,  97 

optical  iridectomy,  164 

optico-ciliary  neurotomy,  112 

Pagenstecher's   sutures   for    ptosis. 
76 

Panas's,  for  ptosis,  83 
for  trichiasis,  36 

paracentesis  of  cornea,  205 


INDEX. 


Operations,  paralytic  ectropion,  52 
plastic,  for  trichiasis,  40 
posterior   sclerotomy   in    glaucoma, 

196 

precorneal  iridotomy,  165 
preliminary  iridectomy,  156 
prolapse  of  iris,  209 
pterygium,  231 
ptosis,  71 
summary,  82 

removal  of  partial  cataract,  163 
Rogman's,    for     complete    symble- 

pharon.  121 

Sach's,  for  anterior  synechia,  219 
Saemisch  section,  230 
seclusion  of  pupil,  208 
secondary  cataracts,  159,  169 
secondary  glaucoma,  205 
senile  ectropion,  43 

Kuhnt-Szymanowski,  44 
serpiginous  ulcers,  230 
shortening  of  lid  for  senile  ectropion, 

44 

simple  extraction,  156 

simultaneous  muscle,  97 

spastic  ectropion,  42 

spastic  entropion,  58 

strabismus.  84 

applicability  of,  92 

symblepharon,  120 

tarsorrhaphy,  65 

tattooing  of  cornea,  232 

tenotomy,  85 

total  cataract  in  young  adults,  164 

transfixion,  208 

transplantation  of  cornea,  216 

transplantation  for  pterygium,  231 

trichiasis,  32 

Hotz-Anagnostakis,  32 

Jaesche-Arlt,  39 

Panas's,  36 

Von   Hippel's   corneal   transplanta- 
tion, 218 

Ophthalmic  assistant,  duties  of,  236 
Ophthalmoscope  examination  in  cases  of 

foreign  body  in  eyeball,  222 
Optic  nerve,  resection  of,  in  enucleation, 
no 

iridectomy,  164 

indications  for,  168 

results  of,  168 
Optico-ciliary  neurotomy,  112 

anesthesia,  112 

indications,  112 

Orbicularis  muscle  in  excision  of  lach- 
rymal sac,  3 

17 


Orbital  cavity,  exenteration  of,  113 
opening  of,  1 7 

fat  in  excision  of  lachrymal  sac,  12 
lachrymal  gland,  excision  of,  24 


Pagenstecher's  sutures  for  ptosis,  76 
Pain  during  iridectomy  for  glaucoma,  188 
Painful  amaurotic  eye,  operation  in,  no 
Palpebral  fissure,  complete  closure  of,  69 
operation  for  lengthening,  61 
lachrymal  gland,  excision  of,  22 
dressing  after,  24 
results,  24 
technic,  22 
ligament,  internal,  i 
Panas's  operation  for  ptosis,  83 
for  trichiasis,  36 
disadvantages,  38 
incision,  36 
results,  38 
sutures  in,  37 
technic,  36 

Panophthalmitis,  operation  in,  in 
Paracentesis  of  cornea,  205 
Paralytic  ectropion,  52 

squint,  operations  for,  101 
Partial  cataract,  discission  for,  163 
kerataplasty,  217 
trichiasis,  39 
Passing  of  probes  in  new-born  children. 

29 

Pedicled  flaps  in  eyelid  operations,  115 
Penetrating  wounds  of  eyeball,  226 
Percentage  of  prolapse  of  iris  in  extrac- 
tion without  iridectomy,  156 
Perforation   of  sclera  in  posterior  scle- 
rotomy, 197 
Permeability  of  lachrymal  passages,  test 

for,  30 
Persistent  suppuration  after  excision  of 

lachrymal  sac,  18 

Phenomena  indicating  prolapse  of  vitre- 
ous, 153 

Pince-ciseaux,  De  Wecker's,  129 
Plastic   operations  on   eyelids,    Dieffen- 

bach's,  115 

Dieffenbach-Buediner,  117 
Fricke's,  115 
with  pedicled  flaps,  115 
for  symblepharon,  120 
for  trichiasis,  40 
Pointed  tenaculum  used  to  open  anterior 

lens-capsule,  134 

Position  of  conjunctiva!  flap  after  extrac- 
tion, 139 


258 


INDEX. 


Position  of  eye  after  strabismus  opera- 
tions, 94 
faulty,  of  incision  in  anterior  scler- 

otomy,  195 

foreign  body  in  eyeball,  223 
incision  for  iridectomy  in  glaucoma, 

1 80 
knife  during  incision  for  extraction, 

128,  143 

Possibility  of  recurrence  of  trichiasis  after 
Hotz-Anagnostakis  operation, 
36 

after  Panas's  operation,  38 
Posterior  sclerotomy  as  an  adjunct  to 
removal   of  foreign  bodies   in 
vitreous,  199 

for  detachment  of  retina.  198 
in  glaucoma,  196 
incision,  197 
indications  for,  198 
Pravaz's  syringe,  15 
Precautions  during  cyclodialysis,  201 
Precorneal  iridotomy,  165 
Preliminary  iridectomy,  156 
Preparation  of  upper  lid  in  tarsorraphy, 

66 

Pressure-bandages,  244 
Pressure-dressing  after  iridotomy,  171 
Prevention   of   hemorrhage   after   irido- 
tomy, 171 

Primary  glaucoma,  cyclodialysis  in,  203 
Principal  value  of  posterior  sclerotomy, 

198 
Procedure  in  old  injuries  from  foreign 

bodies,  229 
Prognosis  for  foreign  bodies  in  eyeball, 

227 

Progressive  corneal  ulcers,  corneal  punc- 
ture in,  206 
Prolapse  of  chorioid  in  scleral  wounds, 

treatment  of,  214 
ciliary    body    in    scleral    wounds, 

treatment,  214 
Prolapse  of  iris  in  anterior  sclerotomy, 

196 

conjunctivoplasty  in,  212 
excision  of,  after  simple  extraction, 

157 

operations  for,  209 
percentage  of,  in  extraction  without 

iridectomy,  156 
time  for  excision  after,  215 
vitreous  in  cataract  extraction,  148 
as  a  cause  of  secondary  glaucoma, 

207 

during  discission,  162 
in  iridectomy  for  glaucoma,  190 


Prolapse   in   linear   extraction   for    soft 

cataract,  179 
sequela?  of,  154 
Probes,  Bowman's,  27 
conical,  24 
hollow,  30 

Probing  in  excision  of  lachrymal  sac,  12 
lachrymal,  24 
of  lachrymo-nasal  duct,  27 
contraindications,  31 
indications  for,  29 
in  new-born,  29 
Pterygium,  operations  for,  231 
Arlt's,  232 
transplantation,  231 
Ptosis   following  excision   of   lachrymal 

gland,  24 
operations  for,  71 
Everbusch's,  77 
Hess's,  71 
Motais's,  83 
Pagenstecher's,  77 
Panas's,  83 
summary  of,  82 
Puncture  of  cornea,  206 
Pupil,  seclusion  of,  operation  for,  208 
Purposes  of  iridotomy,  171 

R 

Rays,  Rontgen,  in  foreign  bodies  in  eye- 
ball, 222 
Rectus  externus,  tenotomy  of,  86,  96 

internus,    advancement    of,    indica- 
tions for,  101 
tenotomy  of,  84 

Reisinger's  double  tenaculum,  150,  151 
Removal  of  cortical  substance  in  extrac- 
tion without  iridectomy,  157 
lens    in    linear    extraction    of    soft 

cataract,  176 
partial  cataract,  163 
totally  opaque  lenses,  discission  for, 

163 

Repetition  of  iridotomy,  172 
puncture  of  cornea,  206 
Reposition  of  iris  after  extraction  of  len*. 

138 

in  iridectomy  for  glaucoma,  186 

complications  during,  189 
Resection  of  lachrymal  sac,  i 

optic  nerve  in  enucleation,  no 

palpebral  lachrymal  gland,  22 
Results  of  anterior  sclerotomy,  196 

cyclodialysis,  203 

Dieffenbach's  operation  on  eyelids, 
117 


Kuhm-S/ymano\vski    operation    for 

senile  ectropion.   ;  i 
operation  for  cicatricial  ectropion.  =14 
operation  for  >enile  entropion.  60 
optical  iridectomy.   i6S 
I'anas's  operation  for  trichiasis.   ^S 


Results    ot     Kverbusch's    operation     for       Scleral  sutures.  24 

ptosis.  So  wounds,  treatment  of.  214 

excision  ot  lachrymal  gland.  24  Sclerotomy.    anterior,    accidents    during. 

sac.  21  10.5 

Hess's  ptosis  operation.   75  in  glaucoma,   ig^ 

Hotz-Anagnostakis  operation.  y>  indications,   igf> 

intralaniellar  incision  in.    ig- 
iridodialv>is.   igo 
re.-ults  of.   i  go 
po-ten'or.   for  detachment  of  retina. 

igS 

in  glaucoma.   n><> 
incision  in.    107 
indication.-  for.    igS 
plastic  operation  for  trichiasis.  41  Scopalamin-morphin  ane.-the.-ia.  24^ 

probing  lachrymo-nasal     net.  27  Seclusion  of  pupil,  operation  for,  208 

simultaneous  tenotomy  and  advance-       Second  incision  in    Kuhnt-Szymanowski 

meiit.  07  operation.  48 

tar-orrhaphy.  68  method    of    operating    for    anterior 

Retention  of  particles  of  mucous  mem-  synechia.  221 

brane    after    excision    of    lach-  step    in    Kuhm-S/ymanow-ki   oper 

rymal  sac.  18  ation.  40 

Retina,  detachment  of.   posterior  sclero-       Secondarv  cataract,  operation  for.   150 

tomy  tor.   ig8  Bowman's  discission.   i6g 

following  prolapse  of  vitreou.-.  155  capsulotomv.   170 

Retraction    of    caruncle    following    teno- 
tomy,  101 
Rogman's  operation  for  complete  symble 

pharon.   121 

Roller  forceps.   Knapp's.  2^4 
Ront^en   ray-  in    foreign  bodies    in  eye- 
ball.'222 
Rules  governing  excision  of  iris.  210 

the   incision    in    cataract   extraction. 

142 

operations     in     convergent     strabis- 
mus. 08 
operations  in  divergent  .-trabi.-mus.gg 


combined  discission.   170 
discission.    r6g 

disci.-.-ion  through  -clera.   172 
glaucoma,  operations  for.  205 

iridectomy  in.  206 
transfixion.  208 


jjosterior    sclerotomy    in    glaucoma. 

197 

Rii|)ture.  spontaneous,  of  lens-capsule  in 
iridectomv  tor  glaucoma,  igi 


Senile  cataract,  extraction  of.   124 

ectropion.  operations  for.  4^ 

excision,  44 

K.uhm's.  44 

Kuhnt-S/ymaiiowski.  44 

.shortening  of  lid  for.  44 

entropion,  4^.  51) 

operations,  ;g 

operations  for.  51; 

exci.-ion.  _;g 

operations.  ( iraete's.  50 
Sec|Uel;e  of   prolap-e  of  vitreous.    154 

tenotomv.    ici 


Sac.  excision  of  lachrymal,  i 
Sachs'  lamp.  221; 

operation  for  anterior  synechia.  2ig 

Saemisch  section  in  serpiginous  ulcer.  2  ^o  Serpiginous  ulcer,  iridectomy  tor.  2^1 

Scars,   cystic,   after  iridectomy   for  glau-  operati\e  therapy  ot.  2^0 

coma.  221  Saemisch  section  in.  2  yO 

Scissors  in  enucleation.   105  subconjunctival  injections  in.  2^0 

iris,   i2g  thermocautery  in.  2,^0 

Sclera.   discission   through,   in   >Vn>ndary  Severaiue  of  optic  nerve  in  enucleation, 

cataract,   172  IGO 

extraction  of  foreign  bodies  through  Shorten  in-.:  of    lid    for  senile   ectropion. 

an  opening  in.  227  44 


260 


INDEX. 


Shortness  of  corneal  incision  in  cataract 

extraction,  141 
Shrunken  lens  in  children,  operation  for, 

164 

Sideroscope,  223 
Sideroscope  in  foreign  bodies  in  eye-ball, 

222 
Significance    of    prolapse    of    vitreous 

during  extraction,  148 
Signs  of  prolapse  of  vitreous,  153 
Simple  extraction,  156 
Simultaneous    advancement     of    rectus 
externus  and  tenotomy  of  rectus 
internus  of  one  eye,  97 
Size    of    lens    influencing   expression  in 

extraction,  147 
Skin-graft  flaps  in  operation  for  cicatri- 

cial  ectropion,  55 

Slitting  of  lachrymal  canaliculus,  26 
indications,  26 
technic  of,  26 

Small  magnet  in  foreign  bodies  in  eye- 
ball, 226 
Snellen's  cup,  244 

suture  for  spastic  ectropion,  42 
Soft  cataract,  linear  extraction  for,  174 
Spastic  ectropion,  42 
operations  for,  42 
operations  for,  Snellen's  suture.  42 
entropion,  58 
operations  for,  58 
Gaillard's  suture,  58 
Speculum,  lid,  236 

Muller's  tearsac,  3 
Spencer   Watson   operation   for   partial 

trichiasis,  39 
Splitting  of  cornea,  230 
Spontaneous  rupture  of  lens-capsule  in 

iridectomy  for  glaucoma,  191 
Spoon,    Daviel's,    in   foreign   bodies   in 

eye-ball,  227 
in  expression  of    cataractous     lens, 

136 

Desmarres',  152 
Squint,   paralytic,   indications  for  oper 

ation  in,  101 

Staphyloma,  corneal,  operations  for,  233 
Stenopaeic  disk,  Fritsch's  movable,  167 
Steps  in  Kuhnt-Syzmanowski  operation, 

44 

Steps  in  enucleation,  103 
Strabismus,   convergent,   indications  for 

operations  in,  98 
divergent,  indications  for,  99 
operations,  84 
applicability,  92 


Stretching  of  muscle  in  advancement,  87 
Subconjunctival    injections    for    serpigi- 

nous  ulcer,  230 
Subcutaneous   injection   of  cocain-solu- 

tion,  243 
Subluxation   of   lens   in   iridectomy   for 

glaucoma,  191 
Summary  of  operations  for  ptosis,  82 

wounds  of  eye-ball,  226 
Superficial    fascia   in   excision   of   lach 

rymal  sac,  3 
Supporting  sutures,  indications  for,  100 

in  tenotomy,  93 
Suppuration,  persistent,  after  excision  of 

lachrymal  sac,  18 
Sutures  in  advancement  of  extraocular 

muscles,  87 
in  canthoplasty,  62 
in  conjunctivoplasty,  212 
counteracting,  in  tenotomy,  95 
in  Dieffenbach-Buediner  operation, 

118 
in  Everbusch's  operation  for  ptosis, 

78 

in  excision  of  lachrymal  sac,  12 
in  Fuchs's  method  of  tarsorrhaphy,  67 
Gaillard's,  for  spastic  entropion,  58 
in     Graefe's    operation    for    senile 

entropion,  60 

in  Hess's  operation  for  ptosis,  71 
in  Hotz-Anagnostakis  operation,  34 
in  Kuhnt's  method  of  canthoplasty 

64 

in  Kuhnt-Szymanowski  operation,  48 
in  operation  for  cicatricial  ectropion, 

53 

Pagenstecher's,  for  ptosis,  76 
in  Panas's  operation  for  trichiasis,  37 
scleral,  214 

Snellen's,  for  spastic  ectropion,  42 
supporting,  in  tenotomy,  93 
after  tenotomy  of  rectus  internus,  84 
Suturing  of  conjunctiva  in  cyclodialysis, 

202 

Swelling  of  lens,  corneal  puncture  in,  206 
Symblepharon,  complete,  121 

operations  for,  120 

Sympathetic  affections,  operations  in,  no 
Symptoms  of  prolapse  of  vitreous,  153 
Synechiae,  anterior,  operations  for,  219 

extensive,  iridectomy  in,  211 

following  cataract  extraction,  142 
Syringe,  Anel's,  28 

Pravaz's,  15 

Szymanowski  operation  for  senile  ectro- 
pion, 44 


INDEX. 


Tampon  in  enucleation,  109 
Tarso-orbital  faccia,  23 
Tarsorrhaphy,  65 

external,  65 

Fuchs's  method  of,  65 

incisions  in,  66 

indications  for,  65,  68 

internal,  69 

median  (v.  Arlt),  70 

object  of,  65 

results  of,  68 
Tarsus,    excision    of,    in    Kuhnt-Szyma- 

nowski  operation,  46 
Tattooing  of  cornea,  168,  232 

Froehlich's  method  of,  233 
Tear-conduction,  29 
Tearing  of  conjunctiva  during     cataract 

extraction,  140 

Tearsac  speculum  (Miiller's),  3 
Technic  of  advancement  of  extraocular 
muscles,  86 

anesthesia  of  lachrymal  apparatus, 

15 
anterior  sclerotomy,    (De  Wecker), 

193 

Arlt's  median  tarsorrhophy,  70 
Arlt's  operation  for  pterygium,  232 
Beer-Wecker  operation  for  corneal 

staphyloma,  233 
canthoplasty,  61 
conjunct!  voplasty.  212 
corneal  transplantation,  216 
cyclodialysis  (Heine),  199 
De  Wecker's  method  of  transplanta- 
tion of  the  conjunctiva,  214 
Dieffenbach's  operation  on  eyelids, 

"5 

Dieffenbach-Buediner  operation,  117 

dilatation  of  canalicujus,  24 

discission,  159 

for  secondary  cataract,  1 70 

douching  lachrymal  sac,  28 

enucleation,  103 

Everbusch's  operation  for  ptosis,  77 

excision  of  iris,  209 

of  lachrymal  sac,  i 

palpebral  lachrymal  gland,  22 
expression  of  trachoma    granules, 

234 

extraction  of  lens  in  its  capsule,  150 
senile  cataract,  124 
without  iridectomy.  157 
Graefe's  operation  for  senile  entro- 
pion,  59 


Technic  of  Fricke's  operation,  115 
Hess's  operation  for  ptosis,  71 
Hotz-Anagnostakis  operation,  32 
of    introduction    of    Pagenstecher's 

sutures  for  ptosis,  76 
iridectomy    in    cataract    extraction, 

129 

iridectomy  for  glaucoma,  180 
iridotomy    for    secondary    cataract, 

170 

keratoplasty,  216 

Kuhnt's  method  of  canthoplasty,  63 
Kuhnt's  conjunctiroplasty,  212 
Kuhnt-Szymanowski   operation   for 

senile  ectropion,  44 
linear  extraction  for   soft   cataract, 

174 

magnet  operations,  224 
opening    anterior     lens-capsule    in 

extraction,  131 

operation  for  cicatricial  ectropion,  52 
for  corneal  staphyloma,  233 
for  entropion,  58 
for  symblepharon,  120 
optical  iridectomy,  165 
optico-ciliary  neurotomy,  112 
Panas's  operation  for  trichiasis,  36 
paracentesis  of  cornea,  205 
partial  transplantation  of  cornea,  217 
plastic  operation  for  trichiasis,  40 
posterior  sclerotomy    in    glaucoma, 

196 

precorneal  iridotomy,  165 
probing  lachrymo-nasal  duct,  27 
Rogman's    operation    for    symble 

pharon,  121 
simple  extraction,  156 
slitting  the  lachrymal  canaliculus,  26 
tarsorrhophy,  65,  69 
tattooing  of  cornea,  232 
rectus  externus,  86 
tenotomy  of  rectus  internus,  84 
total  keratoplasty,  218 
transfixion  for  seclusion  of  pupil,  208 
transplantation  operation  for  ptery- 
gium, 231 

Yon    Hippel's   corneal   transplanta- 
tion, 218 

Tenaculum,  pointed,  used  to  open  ante- 
rior lens-capsule,  134 
Reisinger's  double,  150,  151 
Tenotomy.  ^4 

and  advancement  performed  simul- 
taneously, 97 

counteracting  sutures  in,  95 
rectus,  externus,  86,  96 


262 


INDEX. 


Tenotomy,  rectus  internus,  84 
sequelae  of,  101 
supporting  sutures,  93 

Test     for     permeability     of     lachrymal 
passages,  30 

Therapy,  operative,  of  serpiginous  ulcer, 
230 

Thermocautery  in  serpiginous  ulcers,  230 

Thickening  of  capsule  of  lens  in  cataract 
extraction,  145 

Third  step  in  Kuhnt-Szymanowski  oper- 
ation, 48 

Time  for  excision  of  iris  after  prolapse, 

2I5 

operation  in  glaucoma,  189 
Toilet  of  the  eye  after  extraction,  138 
Total  cataract  in  young  adults,  operation 

for,  164 

keratoplasty,  218 
staphyloma,  operation  in,  in 
symblepharon,  operations  for,   121, 

122 

Totally  opaque  lenses,  discission  for,  163 
Trachoma  granules,  expression  of,  234 
Transfixion    of    iris    in    iridectomy    for 

glaucoma,  187 
for  seclusion  of  pupil,  208 
Transparent  lens,  discission  of,  161 
Transplantation     of     conjunctiva,     De 

Wecker's  method  of,  214 
cornea,  216 
partial,  217 
total,  218 
Von  Hippel's,  218 
for  pterygium,  231 
Trephine,  corneal,  Von  Hippel's  218 
Trephining  of  cornea,  216 

for  anterior  synechia,  219 
Treatment     of     expulsive     hemorrhage 

during  extraction,  155 
prolapse  of  vitreous  during  extrac- 
tion, 148 
wounds    with    prolapse    of    ciliary 

body  or  chorioid,  214 
serpiginous  ulcer,  230 
wounds  of  eyeball,  226 
Trichiasis,  electrolysis  in,  41 
epilation  in,  41 
operations  for,  32 
Flarer's  method,  38 
Hotz-Anagnostakis  method,  32 
Jaesche-Arlt,  39 
Panas's  method,  36 
plastic,  40 
Spencer  Watson  method,  39 


Tuberculous  disease  of  lachrymal,  sac,  20 
Turning    down    of    corneal    flap    after 

extraction,  154 
Turning  of  the  lancet  in  iridectomy  for 

glaucoma,  182 

Two  needles,  discission  with,  169 
Tying  of  sutures  in  Hess's  operation  for 

ptosis,  72 

U 

Ulcer,  serpiginous,  operative  therapy  of, 
230 

Ulcers,  progressive  corneal,  corneal  punc- 
ture in,  206 

Ultimate  result  of  excision  of  lachrymal 
sac,  21 

Undercorrection  after  tenotomy  for  con 
vergent  squint,  94 

Unpedicled  flap  operation  in  total 
symblepharon,  123 

Upper  lid,  spastic  ectropion  of,  42 


Vertical  incision  in  iridotomy,  171,  172 
Vision  in  cases  of  foreign  body  in  eyeball, 

222 
Vitreous,  extraction  of  foreign  bodies  in, 

228 

fluid,  154 

prolapse  of,  after  extraction,  148 
during  discission,  162 
in  iridectomy  for  glaucoma,  190 
in  linear  extraction  of  soft  cata- 
ract, 179 
sequelae  of,  154 
removal  of  foreign  bodies  in,  hypos- 

terior  sclerotomy,  199 
Von  Hippel's  corneal  transplantation,  218 
trephine,  218 


Watson  operation  for  partial  trichiasis,  39 
Weber's  knife,  27 

loop,  150 
Widening  of  palpebral  fissure  following 

tenotomy,  101 
Withdrawal  of  the  knife  in  iridectomy 

for  glaucoma,  183 
Wounds  in  cornea  in  excision  of  iris,  210 

eyeball,  penetrating,  226 

summary  of,  226 

gaping,  in  cataract  extraction,  141 

lens-capsule  in  excision  of  iris,  210 

scleral  treatment  of,  214 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


Form  L9-Series  4939 


UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


A     000414520     7 


